=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598119273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID PAULSON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2016
-----------------------------------------------------
Last Update Date | 08/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 MAXWELL DR STE 100
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-690-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1610 MAXWELL DR STE 100
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-495-0554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D13705
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | D13705
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------