Provider Demographics
NPI:1003991944
Name:BLACKDUCK DENTAL CLINIC
Entity Type:Organization
Organization Name:BLACKDUCK DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BENGTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-835-4227
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:BLACKDUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56630-0308
Mailing Address - Country:US
Mailing Address - Phone:218-835-4227
Mailing Address - Fax:218-835-7512
Practice Address - Street 1:49 SUMMIT AVE. SE
Practice Address - Street 2:
Practice Address - City:BLACKDUCK
Practice Address - State:MN
Practice Address - Zip Code:56630
Practice Address - Country:US
Practice Address - Phone:218-835-4227
Practice Address - Fax:218-835-7512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN81202BEOtherBLUE CROSS BLUE SHIELD
MN81202BEOtherBLUE CROSS BLUE SHIELD