1750584173 NPI number — ROY E. PAULSON JR PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750584173 NPI number — ROY E. PAULSON JR PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROY E. PAULSON JR PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CASPER CHILDREN'S DENTAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750584173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 N. KENWOOD ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82601-2724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-266-1997
Provider Business Mailing Address Fax Number:
307-237-4424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 N. KENWOOD ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-2724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-266-1997
Provider Business Practice Location Address Fax Number:
307-237-4424
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAULSON
Authorized Official First Name:
ROY
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
307-266-1997

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112331900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: A0H1301FUMCMEAT . This is a "CMS EHR CERTIFICATION" identifier . This identifiers is of the category "OTHER".




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