Provider Demographics
NPI:1306213798
Name:DETTLING, PAUL JEFFREY (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEFFREY
Last Name:DETTLING
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 1:615 66TH AVE N STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1666
Mailing Address - Country:US
Mailing Address - Phone:763-560-8980
Mailing Address - Fax:763-560-0611
Practice Address - Street 1:615 66TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1667
Practice Address - Country:US
Practice Address - Phone:763-560-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6125111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician