Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 019022926 | IL |
NPI | 1114163185 |
---|---|
Provider Name | Dr. Paul John Denemark |
First Address | Downers Grove, IL 60515-4520 |
Second Address | Downers Grove, IL 60515-4520 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2008 |
Last Update Date | 19/08/2016 |