Provider Demographics
NPI:1417000779
Name:GRACZA, EDWARD REZSO (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:REZSO
Last Name:GRACZA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:223 S MAIN
Mailing Address - City:KARLSTAD
Mailing Address - State:MN
Mailing Address - Zip Code:56732-0223
Mailing Address - Country:US
Mailing Address - Phone:218-436-2946
Mailing Address - Fax:218-436-2947
Practice Address - Street 1:223 S MAIN
Practice Address - Street 2:
Practice Address - City:KARLSTAD
Practice Address - State:MN
Practice Address - Zip Code:56732-0223
Practice Address - Country:US
Practice Address - Phone:218-436-2946
Practice Address - Fax:218-436-2947
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10309122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist