Provider Demographics
NPI:1760172472
Name:MICHAELSON, PAUL RUDOLPH (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RUDOLPH
Last Name:MICHAELSON
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 1:121 E FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5589
Mailing Address - Country:US
Mailing Address - Phone:701-223-1194
Mailing Address - Fax:
Practice Address - Street 1:121 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5589
Practice Address - Country:US
Practice Address - Phone:701-223-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ND24841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program