Provider Demographics
NPI:1073671764
Name:BENDER, PAUL WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WILLIAM
Last Name:BENDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 GRAYSTONE PLZ
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3034
Mailing Address - Country:US
Mailing Address - Phone:218-847-2631
Mailing Address - Fax:218-847-0048
Practice Address - Street 1:119 GRAYSTONE PLZ
Practice Address - Street 2:SUITE 110
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3034
Practice Address - Country:US
Practice Address - Phone:218-847-2631
Practice Address - Fax:218-847-0048
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4590111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNV02212Medicare UPIN