Provider Demographics
NPI:1215542618
Name:GRACE A. WARREN DDS, CORP
Entity Type:Organization
Organization Name:GRACE A. WARREN DDS, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-721-1272
Mailing Address - Street 1:4110 CEDAR AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3433
Mailing Address - Country:US
Mailing Address - Phone:612-721-1272
Mailing Address - Fax:612-721-1803
Practice Address - Street 1:4110 CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3433
Practice Address - Country:US
Practice Address - Phone:612-721-1272
Practice Address - Fax:612-721-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-11
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN143320200Medicaid