Provider Demographics
NPI:1598826182
Name:MONDALE, BRIAN PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:MONDALE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10600 OLD COUNTY RD 15
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:763-512-8500
Mailing Address - Fax:763-512-8592
Practice Address - Street 1:10590 WAYZATA BLVD
Practice Address - Street 2:#270
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5512
Practice Address - Country:US
Practice Address - Phone:952-512-8500
Practice Address - Fax:952-512-8592
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN744487700Medicare ID - Type Unspecified