Provider Demographics
NPI:1982829420
Name:GRAMMER, GRACIELA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:GRACIELA
Middle Name:
Last Name:GRAMMER
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 1:522 S CASS ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:IL
Mailing Address - Zip Code:62691-1506
Mailing Address - Country:US
Mailing Address - Phone:217-452-7207
Mailing Address - Fax:
Practice Address - Street 1:700 E OAK ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-3157
Practice Address - Country:US
Practice Address - Phone:309-647-1134
Practice Address - Fax:309-647-9545
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01915408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002038Medicaid