MEDICARE: CLEARBROOK DENTAL CLINIC, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	10180	MN

General Provider Information

NPI Number	:	1164511267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARBROOK DENTAL CLINIC, LTD

Provider Business Mailing Address
First Line	:	113 MAIN ST S
Second Line	:
City	:	CLEARBROOK
State	:	MN
Zip	:	56634-0314
Country	:	US
Telephone Number	:	218-776-3558
Fax Number	:	218-776-2112

Provider Business Practice Location Address
First Line	:	113 MAIN ST S
Second Line	:
City	:	CLEARBROOK
State	:	MN
Zip	:	56634-0314
Country	:	US
Telephone Number	:	218-776-3558
Fax Number	:	218-776-2112

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RANDY CARL BEARD
Credential	:	D.D.S.
Telephone Number	:	218-776-3558

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	08/22/2020

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