Provider Demographics
NPI:1831194281
Name:DEHEN, MARK DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:DEHEN
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 1:1706 LOR RAY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1939
Mailing Address - Country:US
Mailing Address - Phone:507-388-7744
Mailing Address - Fax:507-388-8001
Practice Address - Street 1:1706 LOR RAY DR
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-1939
Practice Address - Country:US
Practice Address - Phone:507-388-7744
Practice Address - Fax:507-388-8001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2374111N00000X
AZ4347111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2D596DEOtherBCBS INDIVIDUAL
MN359000346OtherMEDICARE TRANSACTION ACCESS NUMBER
MN230189OtherCHIRO CARE
MN958718700OtherMN CARE
MNT65450Medicare UPIN