Provider Demographics
NPI:1114627205
Name:COMEAU, GRACIE ISABELLA
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:ISABELLA
Last Name:COMEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4518 CEDAR LAKE RD S APT 6
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3750
Mailing Address - Country:US
Mailing Address - Phone:715-751-0299
Mailing Address - Fax:
Practice Address - Street 1:2258 BUNKER LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3900
Practice Address - Country:US
Practice Address - Phone:793-390-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH11422124Q00000X
MNDT164125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist