Provider Demographics
NPI:1912066994
Name:BROCKMAN, BRENDA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:ANN
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 SUNRISE DR E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2231
Mailing Address - Country:US
Mailing Address - Phone:952-945-5147
Mailing Address - Fax:
Practice Address - Street 1:6437 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2174
Practice Address - Country:US
Practice Address - Phone:763-531-7177
Practice Address - Fax:763-535-6284
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND109391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice