Provider Demographics
NPI:1093133696
Name:VALLEY ORAL & FACIAL SURGERY PC
Entity Type:Organization
Organization Name:VALLEY ORAL & FACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:7001-772-7379
Mailing Address - Street 1:3187 BLUESTEM DR STE 4
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8008
Mailing Address - Country:US
Mailing Address - Phone:701-235-7379
Mailing Address - Fax:701-235-0977
Practice Address - Street 1:1165 S COLUMBIA RD STE C
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4007
Practice Address - Country:US
Practice Address - Phone:701-772-7379
Practice Address - Fax:701-772-9643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN497449200Medicaid
ND41399Medicaid
ND14082Medicaid
MN497449200Medicaid