Provider Demographics
NPI:1912567058
Name:ANDREW PETERSON DMD MS PC
Entity Type:Organization
Organization Name:ANDREW PETERSON DMD MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:406-861-8844
Mailing Address - Street 1:9856 HIBISCUS CT
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-3637
Mailing Address - Country:US
Mailing Address - Phone:406-861-8844
Mailing Address - Fax:
Practice Address - Street 1:9856 HIBISCUS CT
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-3637
Practice Address - Country:US
Practice Address - Phone:406-861-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty