1467508226 NPI number — BRAINERD DENTAL CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467508226 NPI number — BRAINERD DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAINERD DENTAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467508226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 LABORE RD.
Provider Second Line Business Mailing Address:
STE. 104
Provider Business Mailing Address City Name:
VADNAIS HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-5186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-431-5995
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11615 STATE AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINERD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-855-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROST
Authorized Official First Name:
WADE
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
MN DHS, DCT EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
651-431-3404

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 970826000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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