Provider Demographics
NPI:1639638265
Name:MARK E PETERSON, DDS
Entity Type:Organization
Organization Name:MARK E PETERSON, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-784-8444
Mailing Address - Street 1:2440 GAYNOR AVE 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 AVE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty