Provider Demographics
NPI:1679765929
Name:PAUL BOETTNER D.D.S. PLLC
Entity type:Organization
Organization Name:PAUL BOETTNER D.D.S. PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOETTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-476-6774
Mailing Address - Street 1:1495 COUNTY ROAD 101 N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447
Mailing Address - Country:US
Mailing Address - Phone:763-476-6774
Mailing Address - Fax:
Practice Address - Street 1:1495 COUNTY ROAD 101 N
Practice Address - Street 2:SUITE 2
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-3078
Practice Address - Country:US
Practice Address - Phone:763-476-6774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty