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General NPI Number Information
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NPI Number | 1699190488
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Entity Type | Organization
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Legal Business Name | BRENNER DENTAL GROUP
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Dates
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Enumeration Date | 03/03/2014
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Last Update Date | 03/03/2014
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Provider Practice Location Address
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Address Line | 102 MARTY DR SUITE 3
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City | BUFFALO
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State | MN
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Zip | 55313-9305
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Country | US
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Telephone | 763-682-2101
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Fax |
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Provider Business Mailing Address
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Address Line | 102 MARTY DR SUITE 3
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City | BUFFALO
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State | MN
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Zip | 55313-9305
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Country | US
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Telephone | 763-682-2101
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. COREY J BRENNER
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Credential | DDS
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Telephone | 612-819-1223
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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 | D11525
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License Number State | MN
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