Provider Demographics
NPI:1861599730
Name:DETHLEFSEN, BRIAN LAWRENCE (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LAWRENCE
Last Name:DETHLEFSEN
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 1:14 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-1209
Mailing Address - Country:US
Mailing Address - Phone:701-742-2750
Mailing Address - Fax:701-742-2909
Practice Address - Street 1:14 N 5TH ST
Practice Address - Street 2:
Practice Address - City:OAKES
Practice Address - State:ND
Practice Address - Zip Code:58474-1209
Practice Address - Country:US
Practice Address - Phone:701-742-2750
Practice Address - Fax:701-742-2909
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10200Medicaid
ND10200Medicaid
NDU63540Medicare UPIN