Provider Demographics
NPI:1841256435
Name:BORDSON, BRENT MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:MICHAEL
Last Name:BORDSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23029
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423
Mailing Address - Country:US
Mailing Address - Phone:612-861-9123
Mailing Address - Fax:612-861-9155
Practice Address - Street 1:825 NICOLLET AVE
Practice Address - Street 2:STE 1131
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402
Practice Address - Country:US
Practice Address - Phone:612-333-2879
Practice Address - Fax:612-333-4816
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist