Healthcare Provider Details

I. General information

NPI: 1164511267
Provider Name (Legal Business Name): CLEARBROOK DENTAL CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 MAIN ST S
CLEARBROOK MN
56634-0314
US

IV. Provider business mailing address

113 MAIN ST S
CLEARBROOK MN
56634-0314
US

V. Phone/Fax

Practice location:
  • Phone: 218-776-3558
  • Fax: 218-776-2112
Mailing address:
  • Phone: 218-776-3558
  • Fax: 218-776-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number10180
License Number StateMN

VIII. Authorized Official

Name: DR. RANDY CARL BEARD
Title or Position: OWNER
Credential: D.D.S.
Phone: 218-776-3558