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General NPI Number Information
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NPI Number | 1679765929
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Entity Type | Organization
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Legal Business Name | PAUL BOETTNER D.D.S. PLLC
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Dates
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Enumeration Date | 08/10/2007
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Last Update Date | 06/15/2012
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Provider Practice Location Address
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Address Line | 1495 COUNTY ROAD 101 N SUITE 2
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City | PLYMOUTH
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State | MN
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Zip | 55447-3078
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Country | US
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Telephone | 763-476-6774
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Fax |
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Provider Business Mailing Address
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Address Line | 1495 COUNTY ROAD 101 N SUITE 2
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City | PLYMOUTH
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State | MN
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Zip | 55447
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Country | US
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Telephone | 763-476-6774
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PAUL D BOETTNER
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Credential | DDS
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Telephone | 763-476-6774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D12160
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License Number State | MN
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