MEDICARE: ELBOW LAKE DENTISTRY, PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1740897156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELBOW LAKE DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 26
Second Line	:
City	:	ELBOW LAKE
State	:	MN
Zip	:	56531-0026
Country	:	US
Telephone Number	:	218-685-4710
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 W DIVISION ST
Second Line	:
City	:	ELBOW LAKE
State	:	MN
Zip	:	56531-4136
Country	:	US
Telephone Number	:	218-685-4710
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. BRADY ELMER WEISPFENNIG
Credential	:	DDS
Telephone Number	:	320-491-0300

Provider Enumeration Date	:	09/29/2020
Last Update Date	:	09/29/2020

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