Healthcare Provider Details

I. General information

NPI: 1245439363
Provider Name (Legal Business Name): JOHN ROBERT GRADY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 WATER ST
SAUK CITY WI
53583-1141
US

IV. Provider business mailing address

918 OAK ST
BARABOO WI
53913-2168
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-4441
  • Fax:
Mailing address:
  • Phone: 608-356-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number53000902
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: