Provider Demographics
NPI:1932754231
Name:GRACE, KOURTNEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KOURTNEY
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KOURTNEY
Other - Middle Name:
Other - Last Name:RUMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1700 E INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 E INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1207
Practice Address - Country:US
Practice Address - Phone:701-222-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND24311223G0001X
AZD0104351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice