Provider Demographics
NPI:1205994373
Name:PETERSEN, BRYAN JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JAMES
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1922
Mailing Address - Country:US
Mailing Address - Phone:208-983-2145
Mailing Address - Fax:
Practice Address - Street 1:120 N A ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1211
Practice Address - Country:US
Practice Address - Phone:208-983-1651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist