Provider Demographics
NPI:1336595941
Name:PETERS, MICHELLE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 FLEUR DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-3105
Mailing Address - Country:US
Mailing Address - Phone:515-287-7773
Mailing Address - Fax:
Practice Address - Street 1:7400 FLEUR DR STE 200
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-3105
Practice Address - Country:US
Practice Address - Phone:515-287-7773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS099391223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program