Provider Demographics
NPI:1295845790
Name:BOTHUN, PAUL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
Last Name:BOTHUN
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:DAKOTA DENTAL ASSOCIATES PC
Mailing Address - Street 2:4000 17TH AVE S
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3905
Mailing Address - Country:US
Mailing Address - Phone:701-775-0641
Mailing Address - Fax:701-746-9328
Practice Address - Street 1:DAKOTA DENTAL ASSOCIATES PC
Practice Address - Street 2:4000 17TH AVE S
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3905
Practice Address - Country:US
Practice Address - Phone:701-775-0641
Practice Address - Fax:701-746-9328
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1791122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
788399OtherUNITED CONCORDIA
ND901791OtherDENTAL SERVICES CORP