Provider Demographics
NPI:1982790879
Name:GRILLY, MARY ELLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:GRILLY
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 1:139 N VERMILION ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4718
Mailing Address - Country:US
Mailing Address - Phone:217-446-7438
Mailing Address - Fax:217-443-2233
Practice Address - Street 1:139 N VERMILION ST
Practice Address - Street 2:SUITE 502
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4718
Practice Address - Country:US
Practice Address - Phone:217-446-7438
Practice Address - Fax:217-443-2233
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice