Provider Demographics
NPI:1255523148
Name:WYTHE FAMILY DENTISTRY
Entity type:Organization
Organization Name:WYTHE FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-228-2222
Mailing Address - Street 1:210 LORETTO DRIVE
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2076
Mailing Address - Country:US
Mailing Address - Phone:276-228-3361
Mailing Address - Fax:276-228-0607
Practice Address - Street 1:210 LORETTO DRIVE
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2076
Practice Address - Country:US
Practice Address - Phone:276-228-3361
Practice Address - Fax:276-228-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty