Provider Demographics
NPI:1427007913
Name:BENGTSON, JOHN CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
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 1:300 SOUTH PARK ST.
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:MN
Mailing Address - Zip Code:55332-0484
Mailing Address - Country:US
Mailing Address - Phone:507-426-7794
Mailing Address - Fax:507-426-7794
Practice Address - Street 1:300 SOUTH PARK ST.
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MN
Practice Address - Zip Code:55332
Practice Address - Country:US
Practice Address - Phone:507-426-7794
Practice Address - Fax:507-426-7794
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND68441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice