Provider Demographics
NPI:1720179302
Name:DONABAUER, BRADLY (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:DONABAUER
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 1:310 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1913
Mailing Address - Country:US
Mailing Address - Phone:218-281-1301
Mailing Address - Fax:
Practice Address - Street 1:310 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1913
Practice Address - Country:US
Practice Address - Phone:218-281-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice