Provider Demographics
NPI:1225099849
Name:GREWAL, GULTAJ (DMD)
Entity Type:Individual
Prefix:
First Name:GULTAJ
Middle Name:
Last Name:GREWAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:1724 MOUNT ROYAL BLVD
Practice Address - Street 2:
Practice Address - City:GLENSHAW
Practice Address - State:PA
Practice Address - Zip Code:15116-2115
Practice Address - Country:US
Practice Address - Phone:412-213-1999
Practice Address - Fax:412-213-6985
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011126770011Medicaid
PA1011126770005Medicaid
PA1011126770010Medicaid
PA1011126770002Medicaid
PA1011126770012Medicaid
PA1011126770013Medicaid
PA1011126770003Medicaid
PA1011126770007Medicaid
PA1011126770009Medicaid
PA1011126770004Medicaid
PA1011126770001Medicaid
PA1011126770008Medicaid
PA1011126770014Medicaid