Provider Demographics
NPI:1477852556
Name:JUST 4 ME PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:JUST 4 ME PEDIATRIC DENTISTRY
Other - Org Name:MARTI PETERSON DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-688-7721
Mailing Address - Street 1:1660 HOPKINS RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1061
Mailing Address - Country:US
Mailing Address - Phone:716-688-7721
Mailing Address - Fax:
Practice Address - Street 1:1660 HOPKINS RD
Practice Address - Street 2:SUITE 107
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1061
Practice Address - Country:US
Practice Address - Phone:716-688-7721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0496201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02411989Medicaid