Provider Demographics
NPI:1689782864
Name:PETERSON, MARK L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
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 1:127 1/2 E SHORT ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1422
Mailing Address - Country:US
Mailing Address - Phone:208-745-6536
Mailing Address - Fax:208-745-0006
Practice Address - Street 1:127 1/2 E SHORT ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1422
Practice Address - Country:US
Practice Address - Phone:208-745-6536
Practice Address - Fax:208-745-0006
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD 17581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice