Provider Demographics
NPI:1710030077
Name:SUKKAWALA, KETAN ARUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:ARUN
Last Name:SUKKAWALA
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 1:1109 ROCK PRAIRIE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8651
Mailing Address - Country:US
Mailing Address - Phone:979-694-5200
Mailing Address - Fax:979-694-5223
Practice Address - Street 1:1103 ROCK PRAIRIE RD STE 1001
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8344
Practice Address - Country:US
Practice Address - Phone:979-694-5200
Practice Address - Fax:979-694-5223
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX196351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19635OtherDENTAL LICENSE
TX009547301Medicaid