Healthcare Provider Details

I. General information

NPI: 1467508226
Provider Name (Legal Business Name): BRAINERD DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/05/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11615 STATE AVE.
BRAINERD MN
56401
US

IV. Provider business mailing address

3200 LABORE RD. STE. 104
VADNAIS HEIGHTS MN
55110-5186
US

V. Phone/Fax

Practice location:
  • Phone: 218-855-8600
  • Fax:
Mailing address:
  • Phone: 651-431-5995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier970826000
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name: MR. WADE RICHARD BROST
Title or Position: MN DHS, DCT EXECUTIVE DIRECTOR
Credential:
Phone: 651-431-3404