Healthcare Provider Details

I. General information

NPI: 1154498426
Provider Name (Legal Business Name): PAUL RICHARD MASTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 W MILHAM AVE
PORTAGE MI
49024-1230
US

IV. Provider business mailing address

1622 W MILHAM AVE
PORTAGE MI
49024-1230
US

V. Phone/Fax

Practice location:
  • Phone: 269-343-8378
  • Fax: 269-343-8479
Mailing address:
  • Phone: 269-381-0564
  • Fax: 269-343-8479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901009951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: