Provider Demographics
NPI:1376885343
Name:POTTER, PAUL DUANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DUANE
Last Name:POTTER
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 1:280 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522-2222
Mailing Address - Country:US
Mailing Address - Phone:217-423-3449
Mailing Address - Fax:
Practice Address - Street 1:280 W NORTH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62522-2222
Practice Address - Country:US
Practice Address - Phone:217-423-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL003-019017257-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist