Organization123 Brush Dental LlcClinic/CenterAmbulatory Health Care FacilitiesPractice Address1670 Beam Ave, Ste 202, Maplewood, MN 55109(651) 779-4195PECOS EnrollmentBased on the most recent information from CMS, provider 123 Brush Dental Llc does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1053807016Provider TypeOrganizationFull Name123 Brush Dental LlcSubpartNoEnumeration Date7/2/2018Last Updated7/2/2018Contact InformationPractice LocationPractice Address1670 Beam Ave, Ste 202, Maplewood, MN 55109Phone(651) 779-4195FaxUnlisted FaxMailing LocationMailing Address1670 Beam Ave, Ste 202, Maplewood, MN 55109Phone(651) 779-4195FaxUnlisted FaxAuthorized OfficialNamePeterson, Vacharee Sriswad (Dentist)Phone(651) 779-4195Provider TaxonomiesCodeDescriptionLicenseCode261QD0000XPrimaryDescriptionClinic/CenterAmbulatory Health Care FacilitiesLicenseD9309Minnesota