Provider Demographics
NPI:1184918906
Name:SUMMERFELT, PETER (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:SUMMERFELT
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:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0542
Mailing Address - Country:US
Mailing Address - Phone:617-686-7085
Mailing Address - Fax:
Practice Address - Street 1:301 N. B ST.
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327
Practice Address - Country:US
Practice Address - Phone:617-686-7085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0385171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68221231Medicaid