Provider Demographics
NPI:1477854818
Name:DR. CARRIE PETERSON DDSPC
Entity Type:Organization
Organization Name:DR. CARRIE PETERSON DDSPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:NAOMI
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:701-232-3379
Mailing Address - Street 1:3226 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3403
Mailing Address - Country:US
Mailing Address - Phone:701-232-3379
Mailing Address - Fax:701-298-0879
Practice Address - Street 1:3226 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3403
Practice Address - Country:US
Practice Address - Phone:701-232-3379
Practice Address - Fax:701-298-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty