Provider Demographics
NPI:1891353678
Name:BILDERBACK, DAN P (DR)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:P
Last Name:BILDERBACK
Suffix:
Gender:M
Credentials:DR
Other - Prefix:DR
Other - First Name:DANIEL
Other - Middle Name:PHILLIP
Other - Last Name:BILDERBACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4640 WINNETKA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4933
Mailing Address - Country:US
Mailing Address - Phone:715-554-1763
Mailing Address - Fax:
Practice Address - Street 1:1633 ROBERT ST S STE B
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3973
Practice Address - Country:US
Practice Address - Phone:651-451-6839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6629111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor