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General NPI Number Information
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NPI Number | 1164511267
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Entity Type | Organization
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Legal Business Name | CLEARBROOK DENTAL CLINIC, LTD
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 113 MAIN ST S
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City | CLEARBROOK
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State | MN
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Zip | 56634-0314
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Country | US
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Telephone | 218-776-3558
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Fax | 218-776-2112
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Provider Business Mailing Address
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Address Line | 113 MAIN ST S
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City | CLEARBROOK
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State | MN
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Zip | 56634-0314
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Country | US
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Telephone | 218-776-3558
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Fax | 218-776-2112
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Authorized Official
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Title or Position | OWNER
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Name | DR. RANDY CARL BEARD
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Credential | D.D.S.
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Telephone | 218-776-3558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 10180
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License Number State | MN
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