Healthcare Provider Details

I. General information

NPI: 1659906204
Provider Name (Legal Business Name): GRAND RAPIDS DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SE 21ST ST
GRAND RAPIDS MN
55744-4268
US

IV. Provider business mailing address

220 SE 21ST ST
GRAND RAPIDS MN
55744-4268
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3438
  • Fax:
Mailing address:
  • Phone: 218-326-3438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN LAMKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 218-326-3438