Provider Demographics
NPI:1831380716
Name:BOETTNER, PAUL D (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:BOETTNER
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 1:1495 COUNTY ROAD 101 N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3078
Mailing Address - Country:US
Mailing Address - Phone:763-476-6774
Mailing Address - Fax:
Practice Address - Street 1:1495 COUNTY ROAD 101 N
Practice Address - Street 2:SUITE 2
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-3078
Practice Address - Country:US
Practice Address - Phone:763-476-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2012-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice