Provider Demographics
NPI:1679601710
Name:GRANATH, CORNELIA (DDS)
Entity type:Individual
Prefix:
First Name:CORNELIA
Middle Name:
Last Name:GRANATH
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 1:2901 WILSHIRE BLVD
Mailing Address - Street 2:#339
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4901
Mailing Address - Country:US
Mailing Address - Phone:310-829-9798
Mailing Address - Fax:
Practice Address - Street 1:2901 WILSHIRE BLVD
Practice Address - Street 2:#339
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4901
Practice Address - Country:US
Practice Address - Phone:310-829-9798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA312711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice