Healthcare Provider Details

I. General information

NPI: 1043712367
Provider Name (Legal Business Name): GAALAAS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 01/12/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 NW 6TH ST
GRAND RAPIDS MN
55744-2663
US

IV. Provider business mailing address

280 NW 6TH ST
GRAND RAPIDS MN
55744-2663
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0377
  • Fax:
Mailing address:
  • Phone: 218-326-0377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13554
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9583
License Number StateMN

VIII. Authorized Official

Name: PEDER A. GAALAAS
Title or Position: ORTHODONTIST
Credential: DDS
Phone: 218-326-0377