Provider Demographics
NPI:1003339466
Name:CARLY M. PETERSCHMIDT, DMD, LLC
Entity Type:Organization
Organization Name:CARLY M. PETERSCHMIDT, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-941-6558
Mailing Address - Street 1:622 E 22ND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2989
Mailing Address - Country:US
Mailing Address - Phone:541-687-2343
Mailing Address - Fax:541-505-9258
Practice Address - Street 1:622 E 22ND AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408
Practice Address - Country:US
Practice Address - Phone:541-687-2343
Practice Address - Fax:541-505-9258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental