Provider Demographics
NPI:1356408900
Name:GRUELL, PHILIP BROWNELL (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BROWNELL
Last Name:GRUELL
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 1:1717 SANTA CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2593
Mailing Address - Country:US
Mailing Address - Phone:510-523-7813
Mailing Address - Fax:510-523-1551
Practice Address - Street 1:1717 SANTA CLARA AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2593
Practice Address - Country:US
Practice Address - Phone:510-523-7813
Practice Address - Fax:510-523-1551
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA228061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice