Healthcare Provider Details

I. General information

NPI: 1699859942
Provider Name (Legal Business Name): GERALD DALE BRUDVIK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 OAK ST.
BRECKENRIDGE MN
56520
US

IV. Provider business mailing address

PO BOX 106
BRECKENRIDGE MN
56520
US

V. Phone/Fax

Practice location:
  • Phone: 218-643-6313
  • Fax: 218-643-6347
Mailing address:
  • Phone: 218-643-6313
  • Fax: 218-643-6347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: