Provider Demographics
NPI:1467487298
Name:IVERSON, PAUL H (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:H
Last Name:IVERSON
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17824Medicaid
ND91802IVOtherMNBS #
ND274817700Medicaid
NDDA9011015544OtherPREFERRED ONE #
NDND200029OtherLHS #
ND1120OtherNDBS #
ND8600235OtherMEDICA #
NDHP38639OtherHEALTHPARTNERS #
ND115958OtherUCARE#
ND676709OtherAMERICA'S PPO/ARAZ #
ND8600256OtherMEDICA #
ND17824Medicaid
ND274817700Medicaid
ND190005862Medicare ID - Type UnspecifiedRR MEDICARE #