Provider Demographics
NPI:1740897156
Name:ELBOW LAKE DENTISTRY, PLLC
Entity type:Organization
Organization Name:ELBOW LAKE DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:ELMER
Authorized Official - Last Name:WEISPFENNIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-491-0300
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:ELBOW LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56531-0026
Mailing Address - Country:US
Mailing Address - Phone:218-685-4710
Mailing Address - Fax:
Practice Address - Street 1:18 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:ELBOW LAKE
Practice Address - State:MN
Practice Address - Zip Code:56531-4136
Practice Address - Country:US
Practice Address - Phone:218-685-4710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty