Provider Demographics
NPI:1457474306
Name:CONGDON, PAUL JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:CONGDON
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 1:1102 BEALL ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-2060
Mailing Address - Country:US
Mailing Address - Phone:715-386-3675
Mailing Address - Fax:715-386-0985
Practice Address - Street 1:1102 BEALL ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-2060
Practice Address - Country:US
Practice Address - Phone:715-386-3675
Practice Address - Fax:715-386-0985
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3247-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33463900Medicaid