Provider Demographics
NPI:1497879951
Name:ORTHODONTIC CARE GROUP
Entity Type:Organization
Organization Name:ORTHODONTIC CARE GROUP
Other - Org Name:ORTHODONTIC CARE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KARIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRADEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-432-1103
Mailing Address - Street 1:14605 GLAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4670 PARK NICOLLET AVE SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-3908
Practice Address - Country:US
Practice Address - Phone:952-432-4941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty