Provider Demographics
NPI:1790849248
Name:GRANTHAM, BRANDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:GRANTHAM
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 1:1801 PATRIOT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522
Mailing Address - Country:US
Mailing Address - Phone:254-547-6453
Mailing Address - Fax:254-547-7401
Practice Address - Street 1:1801 PATRIOT CIRCLE
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522
Practice Address - Country:US
Practice Address - Phone:254-547-6453
Practice Address - Fax:254-547-7401
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX22297122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1878704OtherUNITED CONCORDIA