Provider Demographics
NPI:1497825103
Name:MORTIERE, PAUL JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JACOB
Last Name:MORTIERE
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 1:5958 N CANTON CENTER RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2765
Mailing Address - Country:US
Mailing Address - Phone:734-459-1950
Mailing Address - Fax:734-459-5710
Practice Address - Street 1:5958 N CANTON CENTER RD
Practice Address - Street 2:SUITE 600
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2765
Practice Address - Country:US
Practice Address - Phone:734-459-1950
Practice Address - Fax:734-459-5710
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI014875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist