Provider Demographics
NPI:1851831622
Name:GRANDIN, HARLEY BISHOP (DDS)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:BISHOP
Last Name:GRANDIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9359 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-1751
Mailing Address - Country:US
Mailing Address - Phone:415-317-7331
Mailing Address - Fax:
Practice Address - Street 1:9359 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-1751
Practice Address - Country:US
Practice Address - Phone:415-317-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL018002110390200000X
CA1031511223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program