Provider Demographics
NPI:1841612884
Name:PAUL, JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:PAUL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 EDGEWOOD DR S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3637
Mailing Address - Country:US
Mailing Address - Phone:863-665-6201
Mailing Address - Fax:
Practice Address - Street 1:2024 EDGEWOOD DR S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3637
Practice Address - Country:US
Practice Address - Phone:863-665-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 12035122300000X
SC3011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist