Provider Demographics
NPI:1699824276
Name:PAULSON, PETER JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAY
Last Name:PAULSON
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 131947
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-0022
Mailing Address - Country:US
Mailing Address - Phone:651-357-8647
Mailing Address - Fax:
Practice Address - Street 1:5001 WINNETKA AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4230
Practice Address - Country:US
Practice Address - Phone:763-533-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice