Provider Demographics
NPI:1760626857
Name:FACIAL DIMENSIONS, P.C.
Entity Type:Organization
Organization Name:FACIAL DIMENSIONS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:308-384-1172
Mailing Address - Street 1:710 W KOENIG ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-6556
Mailing Address - Country:US
Mailing Address - Phone:308-384-1172
Mailing Address - Fax:
Practice Address - Street 1:710 W KOENIG ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-6556
Practice Address - Country:US
Practice Address - Phone:308-384-1172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE43721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty