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General NPI Number Information
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NPI Number | 1114627205
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Entity Type | Individual
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Provider Name | GRACIE ISABELLA COMEAU
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Gender | Female
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Dates
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Enumeration Date | 03/07/2023
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Last Update Date | 06/21/2023
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Provider Practice Location Address
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Address Line | 2258 BUNKER LAKE BLVD NW
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City | ANDOVER
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State | MN
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Zip | 55304-3900
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Country | US
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Telephone | 793-390-8995
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Fax |
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Provider Business Mailing Address
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Address Line | 4518 CEDAR LAKE RD S APT 6
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City | MINNEAPOLIS
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State | MN
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Zip | 55416-3750
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Country | US
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Telephone | 715-751-0299
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | H11422
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 125J00000X
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Taxonomy Name | Dental Therapist
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License Number | DT164
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License Number State | MN
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