Provider Demographics
NPI:1750457396
Name:BROWN, RICHARD WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WALLACE
Last Name:BROWN
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:PO BOX 186
Mailing Address - Street 2:123 3RD ST
Mailing Address - City:BALATON
Mailing Address - State:MN
Mailing Address - Zip Code:56115
Mailing Address - Country:US
Mailing Address - Phone:507-734-2251
Mailing Address - Fax:507-734-2077
Practice Address - Street 1:123 3RD ST
Practice Address - Street 2:
Practice Address - City:BALATON
Practice Address - State:MN
Practice Address - Zip Code:56115
Practice Address - Country:US
Practice Address - Phone:507-734-2251
Practice Address - Fax:507-734-2077
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7996351OtherMN TAX ID