Healthcare Provider Details

I. General information

NPI: 1588788053
Provider Name (Legal Business Name): ORTHODONTIC CARE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 COMO AVE
SAINT PAUL MN
55108-1460
US

IV. Provider business mailing address

14605 GLAZIER AVE
APPLE VALLEY MN
55124-7545
US

V. Phone/Fax

Practice location:
  • Phone: 651-917-0790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KARIE T GRADEN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 952-432-1103