Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4027 LAKE DRIVE SE SUITE 130
GRAND RAPIDS MI
49546-8812
US

IV. Provider business mailing address

4027 LAKE DRIVE SE SUITE 130
GRAND RAPIDS MI
49546-8812
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-2100
  • Fax: 616-949-8239
Mailing address:
  • Phone: 616-949-2100
  • Fax: 616-949-8239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

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