Provider Demographics
NPI:1235179466
Name:PETERSON, WAYNE MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:MICHAEL
Last Name:PETERSON
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 1:1138 W A ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2127
Mailing Address - Country:US
Mailing Address - Phone:208-882-9310
Mailing Address - Fax:208-882-8601
Practice Address - Street 1:1138 W A ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2127
Practice Address - Country:US
Practice Address - Phone:208-882-9310
Practice Address - Fax:208-882-8601
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-16861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice