Provider Demographics
NPI:1649369919
Name:GRANTHAM, TABBITHA (DDS)
Entity type:Individual
Prefix:
First Name:TABBITHA
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-2508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 N 25TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5254
Practice Address - Country:US
Practice Address - Phone:804-649-0240
Practice Address - Fax:804-643-4733
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice