Provider Demographics
NPI:1942936406
Name:TAYNE A PETERSON DMD PLLC
Entity Type:Organization
Organization Name:TAYNE A PETERSON DMD PLLC
Other - Org Name:BURLEY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-670-4428
Mailing Address - Street 1:2200 PARK AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2186
Mailing Address - Country:US
Mailing Address - Phone:208-878-6684
Mailing Address - Fax:
Practice Address - Street 1:2200 PARK AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2186
Practice Address - Country:US
Practice Address - Phone:208-878-6684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-27
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty