Provider Demographics
NPI:1013976232
Name:DEBUCK, PETER JOHN (DMD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:DEBUCK
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 1:3501 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6429
Mailing Address - Country:US
Mailing Address - Phone:505-918-1531
Mailing Address - Fax:
Practice Address - Street 1:3501 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6429
Practice Address - Country:US
Practice Address - Phone:505-918-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3328491223G0001X
NMDD27051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93429266Medicaid
NM9180523Medicaid