Provider Demographics
NPI:1114143534
Name:BROWN, REGAN FREDERICK (DDS)
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:FREDERICK
Last Name:BROWN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 SEASONS PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3414
Mailing Address - Country:US
Mailing Address - Phone:651-738-2341
Mailing Address - Fax:651-738-9048
Practice Address - Street 1:227 MERIDIAN DR
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2565
Practice Address - Country:US
Practice Address - Phone:715-246-5150
Practice Address - Fax:651-738-9048
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6077-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI076500280Medicare PIN