Provider Demographics
NPI:1871943332
Name:GILLETT, GRANT BRANDON (DMD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:BRANDON
Last Name:GILLETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E GRANT RD
Mailing Address - Street 2:STE 114-354
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-5797
Mailing Address - Country:US
Mailing Address - Phone:520-209-1608
Mailing Address - Fax:
Practice Address - Street 1:5069 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-6083
Practice Address - Country:US
Practice Address - Phone:336-714-5726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009476122300000X
NC108811223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice