Provider Demographics
NPI:1962586792
Name:O'GRADY, PAUL W (DDS MS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:O'GRADY
Suffix:
Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:4027 LAKE DR SE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8812
Mailing Address - Country:US
Mailing Address - Phone:616-949-2100
Mailing Address - Fax:616-949-8239
Practice Address - Street 1:4027 LAKE DR SE
Practice Address - Street 2:SUITE 130
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8812
Practice Address - Country:US
Practice Address - Phone:616-949-2100
Practice Address - Fax:616-949-8239
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI0178471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4899515Medicaid