Provider Demographics
NPI:1013398387
Name:FAVELA, PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FAVELA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-9443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W12802 CTY HWY A
Practice Address - Street 2:
Practice Address - City:BOWLER
Practice Address - State:WI
Practice Address - Zip Code:54416
Practice Address - Country:US
Practice Address - Phone:715-793-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001069-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist