Healthcare Provider Details

I. General information

NPI: 1649275538
Provider Name (Legal Business Name): DAVID JOHN BENGTSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E 2ND ST
WINTHROP MN
55396
US

IV. Provider business mailing address

PO BOX V
WINTHROP MN
55396-0507
US

V. Phone/Fax

Practice location:
  • Phone: 507-647-5313
  • Fax:
Mailing address:
  • Phone: 507-647-5313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9455
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: