Provider Demographics
NPI:1922594753
Name:JOHNSRUD, BREKKE LEE (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:BREKKE
Middle Name:LEE
Last Name:JOHNSRUD
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:BREKKE
Other - Middle Name:LEE
Other - Last Name:HUDELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS MPH
Mailing Address - Street 1:2020 1ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746
Mailing Address - Country:US
Mailing Address - Phone:218-263-8951
Mailing Address - Fax:218-263-8629
Practice Address - Street 1:2020 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746
Practice Address - Country:US
Practice Address - Phone:218-263-8951
Practice Address - Fax:218-263-8629
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND140801223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice