Provider Demographics
NPI:1992063093
Name:BUCK, PAUL MICHAEL THORSEN (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MICHAEL THORSEN
Last Name:BUCK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 COUNTY ROAD D W STE 12
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3517
Mailing Address - Country:US
Mailing Address - Phone:612-788-9246
Mailing Address - Fax:
Practice Address - Street 1:550 COUNTY ROAD D W STE 12
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-3517
Practice Address - Country:US
Practice Address - Phone:612-788-9246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG173069204E00000X
MND13762204E00000X
ORD9768122300000X, 1223S0112X
WADE608275541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery