Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | D13524 | MN |
N | 204E00000X | Oral & Maxillofacial Surgeon | 65986 | MN |
Y | 204E00000X | Oral & Maxillofacial Surgeon | D13524 | MN |
NPI | 1598146763 |
---|---|
Provider Name | Dr. Benjamin Heggestad |
First Address | Duluth, MN 55811-4132 |
Second Address | Duluth, MN 55811-4132 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2015 |
Last Update Date | 26/07/2021 |