Provider Demographics
NPI:1801683347
Name:GREWAL, SHANNON KIRAN
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KIRAN
Last Name:GREWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-5524
Mailing Address - Country:US
Mailing Address - Phone:248-879-2300
Mailing Address - Fax:
Practice Address - Street 1:111 E LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-5524
Practice Address - Country:US
Practice Address - Phone:248-879-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016026451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice