Provider Demographics
NPI:1720571284
Name:PETERSEN, SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W STATE ST STE 115
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7055
Mailing Address - Country:US
Mailing Address - Phone:208-370-5203
Mailing Address - Fax:208-370-5204
Practice Address - Street 1:450 W STATE ST STE 115
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7055
Practice Address - Country:US
Practice Address - Phone:208-370-5203
Practice Address - Fax:208-370-5204
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-10
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10136122300000X
IDD-50381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist