MEDICARE: DR. PAUL WAYNE NORTHUP 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	1223E0200X	Endodontics	7175	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	822910	OTHER		UNITED CONCORDIA INS

General Provider Information

NPI Number	:	1275634867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL WAYNE NORTHUP DDS

Provider Business Mailing Address
First Line	:	1190 BOOKCLIFF AVE
Second Line	:	#204
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-8159
Country	:	US
Telephone Number	:	970-242-9088
Fax Number	:	970-257-0255

Provider Business Practice Location Address
First Line	:	1190 BOOKCLIFF AVE
Second Line	:	#204
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-8159
Country	:	US
Telephone Number	:	970-242-9088
Fax Number	:	970-257-0255

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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