Provider Demographics
NPI:1902210065
Name:GREWAL, SUKRIT
Entity Type:Individual
Prefix:MR
First Name:SUKRIT
Middle Name:
Last Name:GREWAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 ORLEANS ST APT 102
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4094
Mailing Address - Country:US
Mailing Address - Phone:650-892-4917
Mailing Address - Fax:
Practice Address - Street 1:3778 DIX HWY
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3807
Practice Address - Country:US
Practice Address - Phone:313-386-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2018-03-17
Deactivation Date:2015-01-20
Deactivation Code:
Reactivation Date:2015-08-11
Provider Licenses
StateLicense IDTaxonomies
MI29010220621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry