Provider Demographics
NPI:1689282469
Name:BREKKE, ETHAN JON (DDS)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JON
Last Name:BREKKE
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 1:220 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-2512
Mailing Address - Country:US
Mailing Address - Phone:218-234-8823
Mailing Address - Fax:
Practice Address - Street 1:1432 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2425
Practice Address - Country:US
Practice Address - Phone:218-728-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice