Provider Demographics
NPI:1134106818
Name:BRENNER, COREY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:J
Last Name:BRENNER
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 1:8900 WALNUT ST
Mailing Address - Street 2:BOX 236
Mailing Address - City:ROCKFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55373-0236
Mailing Address - Country:US
Mailing Address - Phone:763-477-5794
Mailing Address - Fax:
Practice Address - Street 1:9000 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MN
Practice Address - Zip Code:55373-0236
Practice Address - Country:US
Practice Address - Phone:763-477-5794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice