Provider Demographics
NPI:1578913844
Name:GRANTHAM, URSULA LANETTE (RDH)
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:LANETTE
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 HARD SCRABBLE RD
Mailing Address - Street 2:SUITE#109-232
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8584
Mailing Address - Country:US
Mailing Address - Phone:803-262-3178
Mailing Address - Fax:
Practice Address - Street 1:216 BARNETBY WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-9599
Practice Address - Country:US
Practice Address - Phone:757-310-1329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3592 IA3389124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist