1689824898 NPI number — COREY J BRENNER DDS PLLC

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 1689824898 NPI number — COREY J BRENNER DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COREY J BRENNER DDS PLLC
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:
ROCKFORD DENTALCARE CENTER
Provider Other Organization Name Type Code:
4
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:
1689824898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8900 WALNUT ST SUITE 450 BOX 236
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55373-0236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-477-5794
Provider Business Mailing Address Fax Number:
763-477-4784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 WALNUT ST
Provider Second Line Business Practice Location Address:
BOX 236
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55373-0236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-477-5794
Provider Business Practice Location Address Fax Number:
763-477-4784
Provider Enumeration Date:
09/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRENNER
Authorized Official First Name:
COREY
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-477-5794

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D11525 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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