Individual
WAYNE DAVID LEROY BENTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3640 TALMAGE CIR STE 216, VADNAIS HEIGHTS, MN 55110-7100
(952) 431-5330
(952) 431-5334
Mailing address
3640 TALMAGE CIR STE 216, VADNAIS HEIGHTS, MN 55110-7100
(952) 431-5330
(951) 431-5334
Taxonomy
Speciality
Code
Description
License number
State
2084P0015X
Psychosomatic Medicine Physician
62533-20
WI
2084P0800X
Psychiatry Physician
62533-20
WI
2084P0800X
Psychiatry Physician
Primary
68407
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0186104
L&I
WA
05
—
1609952407
—
MO
05
—
1609952407
—
WA
05
—
214692001
—
AR
01
—
276890
INTERNAL ID-MOTOR VEHICLE ID
—
Enumeration date
10/27/2006
Last updated
02/28/2023
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