MEDICARE: DR. PAUL ATHANASIUS 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	22DI02428700	NJ
2	1223G0001X	General Practice Dentistry	59641	CA

General Provider Information

NPI Number	:	1942538160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL ATHANASIUS D.D.S

Provider Business Mailing Address
First Line	:	1122 E LINCOLN AVE STE 115
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-1909
Country	:	US
Telephone Number	:	714-282-9131
Fax Number	:	714-282-9134

Provider Business Practice Location Address
First Line	:	1122 E LINCOLN AVE STE 115
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-1909
Country	:	US
Telephone Number	:	714-282-9131
Fax Number	:	714-282-9134

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

Provider Enumeration Date	:	11/29/2009
Last Update Date	:	08/15/2024

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