Provider Demographics
NPI:1528013661
Name:PETERSON, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 GAYNOR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-1830
Mailing Address - Country:US
Mailing Address - Phone:616-784-8444
Mailing Address - Fax:616-784-6912
Practice Address - Street 1:2440 GAYNOR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1830
Practice Address - Country:US
Practice Address - Phone:616-784-8444
Practice Address - Fax:616-784-6912
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13556122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124241245Medicaid
D135560OtherBLUE CROSS ID