Provider Demographics
NPI:1790795235
Name:FORDAHL, BREYNNE STACEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BREYNNE
Middle Name:STACEY
Last Name:FORDAHL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:BREYNNE
Other - Middle Name:STACEY FORDAHL
Other - Last Name:RATNAYAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14727 60TH ST. N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-439-9060
Mailing Address - Fax:
Practice Address - Street 1:14727 60TH ST. N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-9060
Practice Address - Fax:651-379-9893
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12259122300000X
MND122591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist