Provider Demographics
NPI:1841200946
Name:PETERSON, MARVIN A (DMD PC)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE
Mailing Address - Street 2:SUITE #707
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2732
Mailing Address - Country:US
Mailing Address - Phone:503-223-4411
Mailing Address - Fax:503-222-9501
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE #707
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-223-4411
Practice Address - Fax:503-222-9501
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD51831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice