Provider Demographics
NPI:1417671652
Name:PROFILE ORTHODONTICS
Entity Type:Organization
Organization Name:PROFILE ORTHODONTICS
Other - Org Name:PROFILE ORTHODONTICS & FACIAL ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSINK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:531-893-2928
Mailing Address - Street 1:6201 S 58TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3678
Mailing Address - Country:US
Mailing Address - Phone:531-893-2928
Mailing Address - Fax:
Practice Address - Street 1:6201 S 58TH ST STE D
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3678
Practice Address - Country:US
Practice Address - Phone:531-893-2928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty