Provider Demographics
NPI:1356891329
Name:GRISELDA GONZALEZ GRANADOS
Entity type:Organization
Organization Name:GRISELDA GONZALEZ GRANADOS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIAT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRISELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ GRANADOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:800-743-3900
Mailing Address - Street 1:AVE. JUAN DE LA BARRERA # 610
Mailing Address - Street 2:COL. PROHOGAR
Mailing Address - City:MEXICALI
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:21240
Mailing Address - Country:MX
Mailing Address - Phone:01152686-565-6591
Mailing Address - Fax:
Practice Address - Street 1:4275 EXECUTIVE SQ STE 200
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1476
Practice Address - Country:US
Practice Address - Phone:800-743-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2172627122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty