Provider Demographics
NPI:1982395646
Name:GILLE, JONATHAN TAFT (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TAFT
Last Name:GILLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 MASTERS PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3237
Mailing Address - Country:US
Mailing Address - Phone:727-504-1755
Mailing Address - Fax:
Practice Address - Street 1:5638 MISSION CENTER RD STE 107
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4348
Practice Address - Country:US
Practice Address - Phone:619-220-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist