Provider Demographics
NPI:1164643292
Name:DERAGISCH, BRENT D (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:D
Last Name:DERAGISCH
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:PO BOX 1659
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302
Mailing Address - Country:US
Mailing Address - Phone:320-253-7700
Mailing Address - Fax:320-253-9271
Practice Address - Street 1:1500 NORTHWAY DRIVE
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-7700
Practice Address - Fax:320-253-9271
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11953122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist