Provider Demographics
NPI:1043429608
Name:POULOS, JILL ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:ELIZABETH
Last Name:POULOS
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 1:4235 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:CA
Mailing Address - Zip Code:93428-2101
Mailing Address - Country:US
Mailing Address - Phone:805-927-5797
Mailing Address - Fax:
Practice Address - Street 1:4235 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIA
Practice Address - State:CA
Practice Address - Zip Code:93428-2101
Practice Address - Country:US
Practice Address - Phone:805-927-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA326671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice