Provider Demographics
NPI:1316235369
Name:BRACK, ELIZABETH HELEN (DMD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:HELEN
Last Name:BRACK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 16TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1056
Mailing Address - Country:US
Mailing Address - Phone:765-318-0218
Mailing Address - Fax:
Practice Address - Street 1:503 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MN
Practice Address - Zip Code:55307
Practice Address - Country:US
Practice Address - Phone:507-964-2748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013023621122300000X
IL019028692122300000X
MND141271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist