MEDICARE: DR. PAUL ALAN AXTHELM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	681	WY

General Provider Information

NPI Number	:	1710980651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL ALAN AXTHELM DDS

Provider Business Mailing Address
First Line	:	325 W MAIN ST
Second Line	:	STE A
City	:	RIVERTON
State	:	WY
Zip	:	82501-3448
Country	:	US
Telephone Number	:	307-856-8197
Fax Number	:	307-857-0699

Provider Business Practice Location Address
First Line	:	325 W MAIN ST
Second Line	:	STE A
City	:	RIVERTON
State	:	WY
Zip	:	82501-3448
Country	:	US
Telephone Number	:	307-856-8197
Fax Number	:	307-857-0699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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