Provider Demographics
NPI:1871709790
Name:INNIS, PAUL G (DMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:INNIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681179
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068-1179
Mailing Address - Country:US
Mailing Address - Phone:435-649-6332
Mailing Address - Fax:435-649-3144
Practice Address - Street 1:1901 PROSPECTOR AVE
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7207
Practice Address - Country:US
Practice Address - Phone:435-649-6332
Practice Address - Fax:435-649-3144
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144608-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice