Healthcare Provider Details

I. General information

NPI: 1932045143
Provider Name (Legal Business Name): GRANT LONNEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 SAVAGE RD
CHARLESTON SC
29407-4726
US

IV. Provider business mailing address

2146 VESPERS DR
CHARLESTON SC
29414-6240
US

V. Phone/Fax

Practice location:
  • Phone: 843-722-5733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11419
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: