Provider Demographics
NPI:1386893113
Name:GRANNIS, JILL (DMD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:GRANNIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 MOORPARK AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1861
Mailing Address - Country:US
Mailing Address - Phone:805-529-5955
Mailing Address - Fax:805-529-9595
Practice Address - Street 1:530 MOORPARK AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1861
Practice Address - Country:US
Practice Address - Phone:805-529-5955
Practice Address - Fax:805-529-9595
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice