Provider Demographics
NPI:1710184775
Name:PETERS, NOAH J (DDS)
Entity Type:Individual
Prefix:DR
First Name:NOAH
Middle Name:J
Last Name:PETERS
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 1:715 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6808
Mailing Address - Country:US
Mailing Address - Phone:406-728-2840
Mailing Address - Fax:406-728-3083
Practice Address - Street 1:715 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6808
Practice Address - Country:US
Practice Address - Phone:406-728-2840
Practice Address - Fax:406-728-3083
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5512754OtherCHIP
MT41244OtherBCBS
MT0113305Medicaid