Provider Demographics
NPI:1801187430
Name:GRANILLO, NATHAN JOSEPH (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JOSEPH
Last Name:GRANILLO
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 CYNTHIA CRES
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6836
Mailing Address - Country:US
Mailing Address - Phone:951-965-0841
Mailing Address - Fax:
Practice Address - Street 1:1630 EL NITA LN
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4657
Practice Address - Country:US
Practice Address - Phone:951-652-2234
Practice Address - Fax:951-652-5894
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-30
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA590121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics