Healthcare Provider Details

I. General information

NPI: 1427063825
Provider Name (Legal Business Name): GRAND AVENUE DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S 8TH ST
LARAMIE WY
82070
US

IV. Provider business mailing address

303 S 8TH ST
LARAMIE WY
82070
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5647
  • Fax: 307-721-9866
Mailing address:
  • Phone: 307-745-5647
  • Fax: 307-721-9866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number506
License Number StateWY

VIII. Authorized Official

Name: DR. THOMAS MCGARVEY
Title or Position: DENTIST
Credential: DDS
Phone: 307-745-5647