MEDICARE: DR. PAUL D BOETTNER D.D.S.

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	1223G0001X	General Practice Dentistry	D12160	MN

General Provider Information

NPI Number	:	1831380716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL D BOETTNER D.D.S.

Provider Business Mailing Address
First Line	:	1495 COUNTY ROAD 101 N
Second Line	:	SUITE 2
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-3078
Country	:	US
Telephone Number	:	763-476-6774
Fax Number	:

Provider Business Practice Location Address
First Line	:	1495 COUNTY ROAD 101 N
Second Line	:	SUITE 2
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-3078
Country	:	US
Telephone Number	:	763-476-6774
Fax Number	:

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	06/03/2012

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