Provider Demographics
NPI:1225203359
Name:BENGTSON, PAUL ROY (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ROY
Last Name:BENGTSON
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 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 E
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
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN141818100Medicaid
MN141818100Medicaid