MEDICARE: DR. GRANT BRANDON GILLETT D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D009476	AZ
2	1223G0001X	General Practice Dentistry	10881	NC
3	122300000X	Dentist	10881	NC

General Provider Information

NPI Number	:	1871943332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT BRANDON GILLETT D.M.D.

Provider Business Mailing Address
First Line	:	515 E GRANT RD
Second Line	:	STE 114-354
City	:	TUCSON
State	:	AZ
Zip	:	85705-5797
Country	:	US
Telephone Number	:	520-209-1608
Fax Number	:

Provider Business Practice Location Address
First Line	:	5069 UNIVERSITY PKWY
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-6083
Country	:	US
Telephone Number	:	336-714-5726
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	09/20/2021

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