Provider Demographics
NPI:1467611624
Name:MARK L. PETERSON
Entity Type:Organization
Organization Name:MARK L. PETERSON
Other - Org Name:PETERSON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-745-6536
Mailing Address - Street 1:127 1/2 E SHORT ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1422
Mailing Address - Country:US
Mailing Address - Phone:208-745-6536
Mailing Address - Fax:208-745-0006
Practice Address - Street 1:127 1/2 E SHORT ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1422
Practice Address - Country:US
Practice Address - Phone:208-745-6536
Practice Address - Fax:208-745-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD17581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
181636OtherIDAHO SMILES
ID001264500Medicaid
476086OtherUNITED CONCORDIA