Provider Demographics
NPI:1093272148
Name:PETERSON, MELISSA R
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 E END RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7201
Mailing Address - Country:US
Mailing Address - Phone:907-226-2228
Mailing Address - Fax:907-226-2230
Practice Address - Street 1:PO BOX L
Practice Address - Street 2:
Practice Address - City:SELDOVIA
Practice Address - State:AK
Practice Address - Zip Code:99663-0250
Practice Address - Country:US
Practice Address - Phone:907-234-7898
Practice Address - Fax:907-234-7865
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDENA338124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist