Provider Demographics
NPI:1033158969
Name:AGRAWAL, SANJAY (DDS)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:AGRAWAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6056 FOUNTAIN POINTE
Mailing Address - Street 2:APT 6
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7716
Mailing Address - Country:US
Mailing Address - Phone:917-453-0577
Mailing Address - Fax:810-736-3269
Practice Address - Street 1:5475 DAVISON RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1520
Practice Address - Country:US
Practice Address - Phone:810-736-9778
Practice Address - Fax:810-736-3269
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI189651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice