Provider Demographics
NPI:1629487897
Name:FAMILY DENTAL CLINIC
Entity Type:Organization
Organization Name:FAMILY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-447-3855
Mailing Address - Street 1:607 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-2021
Mailing Address - Country:US
Mailing Address - Phone:541-447-3855
Mailing Address - Fax:541-416-9580
Practice Address - Street 1:607 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2021
Practice Address - Country:US
Practice Address - Phone:541-447-3855
Practice Address - Fax:541-416-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty