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General NPI Number Information
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NPI Number | 1245439363
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Entity Type | Individual
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Provider Name | JOHN ROBERT GRADY DDS
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Gender | Male
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Dates
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Enumeration Date | 07/18/2007
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Last Update Date | 07/27/2007
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Provider Practice Location Address
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Address Line | 522 WATER ST
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City | SAUK CITY
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State | WI
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Zip | 53583-1141
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Country | US
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Telephone | 608-643-4441
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Fax |
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Provider Business Mailing Address
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Address Line | 918 OAK ST
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City | BARABOO
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State | WI
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Zip | 53913-2168
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Country | US
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Telephone | 608-356-9595
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 53000902
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License Number State | WI
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