Healthcare Provider Details

I. General information

NPI: 1255414025
Provider Name (Legal Business Name): PEDER AITON GAALAAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 NW FIRST AVE
GRAND RAPIDS MN
55744
US

IV. Provider business mailing address

504 NW FIRST AVE SUITE 200
GRAND RAPIDS MN
55744
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0377
  • Fax:
Mailing address:
  • Phone: 218-326-0377
  • Fax: 218-326-0378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: