Provider Demographics
NPI:1467508226
Name:BRAINERD DENTAL CLINIC
Entity type:Organization
Organization Name:BRAINERD DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MN DHS, DCT EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BROST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-431-3404
Mailing Address - Street 1:3200 LABORE RD.
Mailing Address - Street 2:STE. 104
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5186
Mailing Address - Country:US
Mailing Address - Phone:651-431-5995
Mailing Address - Fax:
Practice Address - Street 1:11615 STATE AVE.
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401
Practice Address - Country:US
Practice Address - Phone:218-855-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970826000Medicaid