Provider Demographics
NPI:1942809637
Name:PDB, DDS, PA
Entity Type:Organization
Organization Name:PDB, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOETTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-476-6774
Mailing Address - Street 1:1485 COUNTY ROAD 101 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3053
Mailing Address - Country:US
Mailing Address - Phone:763-476-6774
Mailing Address - Fax:
Practice Address - Street 1:12736 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6307
Practice Address - Country:US
Practice Address - Phone:763-559-2082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental