Healthcare Provider Details

I. General information

NPI: 1316235369
Provider Name (Legal Business Name): ELIZABETH HELEN BRACK D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 W MAIN ST
ARLINGTON MN
55307
US

IV. Provider business mailing address

56 16TH AVE NE
MINNEAPOLIS MN
55413-1056
US

V. Phone/Fax

Practice location:
  • Phone: 507-964-2748
  • Fax:
Mailing address:
  • Phone: 765-318-0218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2013023621
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019028692
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14127
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: