Provider Demographics
NPI:1801921010
Name:WEATHERS, GRANT WENDELL JR (DDS)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:WENDELL
Last Name:WEATHERS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4272
Mailing Address - Country:US
Mailing Address - Phone:573-471-5155
Mailing Address - Fax:573-471-5299
Practice Address - Street 1:405 TANNER ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4272
Practice Address - Country:US
Practice Address - Phone:573-471-5155
Practice Address - Fax:573-471-5299
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice