Provider Demographics
NPI:1255419370
Name:BRATLIE, STEPHEN PAUL (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PAUL
Last Name:BRATLIE
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 106
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-0106
Mailing Address - Country:US
Mailing Address - Phone:218-643-6313
Mailing Address - Fax:218-643-6347
Practice Address - Street 1:430 OAK ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1241
Practice Address - Country:US
Practice Address - Phone:218-643-6313
Practice Address - Fax:218-643-6347
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN88971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice