Provider Demographics
NPI:1144255431
Name:BENTLEY, MARK FREDERIC (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:FREDERIC
Last Name:BENTLEY
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 1:523 SUNLAND DR STE C
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5799
Mailing Address - Country:US
Mailing Address - Phone:435-628-7040
Mailing Address - Fax:435-674-2646
Practice Address - Street 1:523 E SUNLAND DRIVE
Practice Address - Street 2:C
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-628-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6366574-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060493Medicare PIN