Provider Demographics
NPI:1275634867
Name:NORTHUP, PAUL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WAYNE
Last Name:NORTHUP
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 1:1190 BOOKCLIFF AVE
Mailing Address - Street 2:#204
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8159
Mailing Address - Country:US
Mailing Address - Phone:970-242-9088
Mailing Address - Fax:970-257-0255
Practice Address - Street 1:1190 BOOKCLIFF AVE
Practice Address - Street 2:#204
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8159
Practice Address - Country:US
Practice Address - Phone:970-242-9088
Practice Address - Fax:970-257-0255
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
822910OtherUNITED CONCORDIA INS