=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588808323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAUL D. POTTER, D.D.S., LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2009
-----------------------------------------------------
Last Update Date | 04/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 WEST NORTH ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-423-3449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 WEST NORTH ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-423-3449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PAUL DUANE POTTER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 217-423-3449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19-017-257
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------