Healthcare Provider Details

I. General information

NPI: 1962586792
Provider Name (Legal Business Name): PAUL W O'GRADY DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

4027 LAKE DR 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 Number017847
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: