Provider Demographics
NPI:1538284666
Name:FLETCHER, MARK GRANTHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GRANTHAM
Last Name:FLETCHER
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:PO BOX 161329
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-0023
Mailing Address - Country:US
Mailing Address - Phone:864-578-0043
Mailing Address - Fax:864-578-0044
Practice Address - Street 1:107 PARRIS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316-1924
Practice Address - Country:US
Practice Address - Phone:864-578-0043
Practice Address - Fax:864-578-0044
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4095Medicaid