Provider Demographics
NPI:1902242068
Name:GRANITE HILLS DENTAL TEAM
Entity Type:Organization
Organization Name:GRANITE HILLS DENTAL TEAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARISO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-579-0233
Mailing Address - Street 1:810 JAMACHA RD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-6218
Mailing Address - Country:US
Mailing Address - Phone:619-579-0233
Mailing Address - Fax:619-579-0691
Practice Address - Street 1:810 JAMACHA RD
Practice Address - Street 2:SUITE #104
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-6218
Practice Address - Country:US
Practice Address - Phone:619-579-0233
Practice Address - Fax:619-579-0691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty