Provider Demographics
NPI:1205919479
Name:PETERS, MANFRED HENRY JR (DDS)
Entity type:Individual
Prefix:
First Name:MANFRED
Middle Name:HENRY
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:M
Other - Middle Name:H
Other - Last Name:PETERS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2508 BAY AREA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-1531
Mailing Address - Country:US
Mailing Address - Phone:281-486-8061
Mailing Address - Fax:
Practice Address - Street 1:2508 BAY AREA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-1531
Practice Address - Country:US
Practice Address - Phone:281-486-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89D682OtherBLUE CROSS BLUE SHIELD #
TXB10881-01OtherTEXAS CHIPS