Provider Demographics
NPI:1831456789
Name:ANDVIK, BRADY MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:MICHAEL
Last Name:ANDVIK
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 1:930 37TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-6130
Mailing Address - Country:US
Mailing Address - Phone:218-329-1972
Mailing Address - Fax:
Practice Address - Street 1:303 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1531
Practice Address - Country:US
Practice Address - Phone:763-441-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MND13082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program