Provider Demographics
NPI:1679647747
Name:PODRUCH, PAUL L (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:PODRUCH
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 1:1279 BUSINESS PARK RD
Mailing Address - Street 2:
Mailing Address - City:MINERAL POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53565-1210
Mailing Address - Country:US
Mailing Address - Phone:608-987-3662
Mailing Address - Fax:608-987-3859
Practice Address - Street 1:1279 BUSINESS PARK RD
Practice Address - Street 2:
Practice Address - City:MINERAL POINT
Practice Address - State:WI
Practice Address - Zip Code:53565-1210
Practice Address - Country:US
Practice Address - Phone:608-987-3662
Practice Address - Fax:608-987-3859
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice