Provider Demographics
NPI:1518405943
Name:GJENGDAHL, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GJENGDAHL
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 1:3613 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-4243
Mailing Address - Country:US
Mailing Address - Phone:651-796-8370
Mailing Address - Fax:
Practice Address - Street 1:3613 ROBIN LN
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5530
Practice Address - Country:US
Practice Address - Phone:651-796-8370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6281111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor