Provider Demographics
NPI:1508281395
Name:BRENNER DENTAL GROUP
Entity Type:Organization
Organization Name:BRENNER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-819-1223
Mailing Address - Street 1:106 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-9351
Mailing Address - Country:US
Mailing Address - Phone:763-295-2905
Mailing Address - Fax:
Practice Address - Street 1:106 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-9351
Practice Address - Country:US
Practice Address - Phone:763-295-2905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11525261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental