Provider Demographics
NPI:1619049277
Name:DETTLAFF, PETER P (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:P
Last Name:DETTLAFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:ND
Mailing Address - Zip Code:58577-1165
Mailing Address - Country:US
Mailing Address - Phone:701-462-8656
Mailing Address - Fax:
Practice Address - Street 1:3900 S. BROADWAY ST.
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7534
Practice Address - Country:US
Practice Address - Phone:701-839-8726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND399152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist