MEDICARE: O'GRADY ORTHODONTICS, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1396758595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	O'GRADY ORTHODONTICS, P.C.

Provider Business Mailing Address
First Line	:	4027 LAKE DRIVE SE
Second Line	:	SUITE 130
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8812
Country	:	US
Telephone Number	:	616-949-2100
Fax Number	:	616-949-8239

Provider Business Practice Location Address
First Line	:	4027 LAKE DRIVE SE
Second Line	:	SUITE 130
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8812
Country	:	US
Telephone Number	:	616-949-2100
Fax Number	:	616-949-8239

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAUL WILLIAM O'GRADY
Credential	:	DDS MS
Telephone Number	:	616-949-2100

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	01/07/2009

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