Healthcare Provider Details

I. General information

NPI: 1255523148
Provider Name (Legal Business Name): WYTHE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 05/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 LORETTO DRIVE
WYTHEVILLE VA
24382-2076
US

IV. Provider business mailing address

210 LORETTO DRIVE
WYTHEVILLE VA
24382-2076
US

V. Phone/Fax

Practice location:
  • Phone: 276-228-3361
  • Fax: 276-228-0607
Mailing address:
  • Phone: 276-228-3361
  • Fax: 276-228-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401005623
License Number StateVA

VIII. Authorized Official

Name: GRANT CAMPBELL THROCKMORTON
Title or Position: OWNER
Credential: DDS
Phone: 276-228-2222