Basic Information
| Provider Information | |||||||||
| NPI: | 1861621641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREWAL | ||||||||
| FirstName: | AMAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S.,M.D.S.,B.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLYNN | ||||||||
| OtherFirstName: | AMAN | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.D.S.,M.D.S.,B.D.S. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 NW 27TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973305223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666835 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 530 NW 27TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666835 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN-10325 | CO | N | Dental Providers | Dentist | General Practice | 1223G0001X | 019028052 | IL | N | Dental Providers | Dentist | General Practice | 1223G0001X | D10809 | OR | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 82673551 | 05 | CO | MEDICAID | 1861621641 | 05 | NE | MEDICAID | 130509300 | 05 | WY | MEDICAID |