Healthcare Provider Details

I. General information

NPI: 1487860862
Provider Name (Legal Business Name): PRIYA BALI GREWAL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N BROADWAY STE 102
BALTIMORE MD
21213-1437
US

IV. Provider business mailing address

5113 DUNSTER DR
MCKINNEY TX
75070-8883
US

V. Phone/Fax

Practice location:
  • Phone: 770-916-9000
  • Fax:
Mailing address:
  • Phone: 571-216-6892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number23631
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411043
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14709
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: