Provider Demographics
NPI:1497433676
Name:PISARCIK, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PISARCIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 BUERKLE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55110-1300
Mailing Address - Country:US
Mailing Address - Phone:651-337-5695
Mailing Address - Fax:
Practice Address - Street 1:1384 109TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4542
Practice Address - Country:US
Practice Address - Phone:763-757-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty