Provider Demographics
NPI:1710980651
Name:AXTHELM, PAUL ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALAN
Last Name:AXTHELM
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 1:325 W MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3448
Mailing Address - Country:US
Mailing Address - Phone:307-856-8197
Mailing Address - Fax:307-857-0699
Practice Address - Street 1:325 W MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3448
Practice Address - Country:US
Practice Address - Phone:307-856-8197
Practice Address - Fax:307-857-0699
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice