Provider Demographics
NPI:1821207036
Name:ROY E. PAULSON JR PC
Entity type:Organization
Organization Name:ROY E. PAULSON JR PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-686-7635
Mailing Address - Street 1:2805 CEDAR AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-2000
Mailing Address - Country:US
Mailing Address - Phone:307-686-7635
Mailing Address - Fax:307-237-4424
Practice Address - Street 1:2805 CEDAR AVE STE A
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-2000
Practice Address - Country:US
Practice Address - Phone:307-686-7635
Practice Address - Fax:307-237-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112331901Medicaid