Provider Demographics
NPI:1467508226
Name:BRAINERD DENTAL CLINIC
Entity Type:Organization
Organization Name:BRAINERD DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT MENTAL HEALTH ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KORNRUMPF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-431-5003
Mailing Address - Street 1:PO BOX 64979
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55164-0979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11800 STATE AVE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-7308
Practice Address - Country:US
Practice Address - Phone:218-828-2201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970826000Medicaid