Provider Demographics
NPI:1487949236
Name:GRANDVILLE, THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:GRANDVILLE
Suffix:
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 1:8 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1601
Mailing Address - Country:US
Mailing Address - Phone:631-928-8585
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1601
Practice Address - Country:US
Practice Address - Phone:631-928-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0568161223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry