Provider Demographics
NPI:1396978136
Name:VALLEY ORAL & FACIAL SURGERY PC
Entity type:Organization
Organization Name:VALLEY ORAL & FACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:701-772-7379
Mailing Address - Street 1:2701 9TH AVE S STE F
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8712
Mailing Address - Country:US
Mailing Address - Phone:701-772-7379
Mailing Address - Fax:701-772-9643
Practice Address - Street 1:2701 9TH AVE S STE F
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8712
Practice Address - Country:US
Practice Address - Phone:701-772-7379
Practice Address - Fax:701-772-9643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery