1922594753 NPI number — BREKKE LEE JOHNSRUD DDS, MPH

Table of content: BREKKE LEE JOHNSRUD DDS, MPH (NPI 1922594753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922594753 NPI number — BREKKE LEE JOHNSRUD DDS, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSRUD
Provider First Name:
BREKKE
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUDELSON
Provider Other First Name:
BREKKE
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS MPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922594753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 1ST AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIBBING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-263-8951
Provider Business Mailing Address Fax Number:
218-263-8629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 1ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIBBING
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-263-8951
Provider Business Practice Location Address Fax Number:
218-263-8629
Provider Enumeration Date:
07/04/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D14080 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: D14080 , 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)