Provider Demographics
NPI:1649275538
Name:BENGTSON, DAVID JOHN (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
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 V
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MN
Mailing Address - Zip Code:55396-0507
Mailing Address - Country:US
Mailing Address - Phone:507-647-5313
Mailing Address - Fax:
Practice Address - Street 1:220 E 2ND ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MN
Practice Address - Zip Code:55396
Practice Address - Country:US
Practice Address - Phone:507-647-5313
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1994177-000Medicare UPIN