Provider Demographics
NPI:1275643629
Name:THIELEN, PAUL FREDERICK (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:FREDERICK
Last Name:THIELEN
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 1:318 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-823-3654
Mailing Address - Fax:707-823-2612
Practice Address - Street 1:318 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-823-3654
Practice Address - Fax:707-823-2612
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295001223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health