Provider Demographics
NPI:1932334695
Name:ETCHISON, PAUL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWARD
Last Name:ETCHISON
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 1:820 LARAWAY RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2694
Mailing Address - Country:US
Mailing Address - Phone:815-524-6000
Mailing Address - Fax:
Practice Address - Street 1:820 LARAWAY RD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2694
Practice Address - Country:US
Practice Address - Phone:815-524-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0279031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice