Provider Demographics
NPI:1295875953
Name:PETERSON, JOHN GREGORY (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:PETERSON
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 1:9201 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2502
Mailing Address - Country:US
Mailing Address - Phone:208-375-0185
Mailing Address - Fax:208-375-0305
Practice Address - Street 1:9201 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2502
Practice Address - Country:US
Practice Address - Phone:208-375-0185
Practice Address - Fax:208-375-0305
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist