Provider Demographics
NPI:1174657241
Name:GREMILLION, JAY KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:KEVIN
Last Name:GREMILLION
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:J
Other - Last Name:GREMILLION
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:804 CAROLYN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0105
Mailing Address - Country:US
Mailing Address - Phone:408-761-3061
Mailing Address - Fax:209-579-9521
Practice Address - Street 1:830 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2420
Practice Address - Country:US
Practice Address - Phone:209-384-3434
Practice Address - Fax:209-384-8262
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40442122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40442OtherDDS LICENSE