Provider Demographics
NPI:1720105240
Name:PETER P. DETTLAFF P. C.
Entity Type:Organization
Organization Name:PETER P. DETTLAFF P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:DETTLAFF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-839-8726
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:ND
Mailing Address - Zip Code:58577-1165
Mailing Address - Country:US
Mailing Address - Phone:701-462-8656
Mailing Address - Fax:701-858-1741
Practice Address - Street 1:3900 S. BROADWAY ST.
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7534
Practice Address - Country:US
Practice Address - Phone:701-839-8726
Practice Address - Fax:701-858-1741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND399152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty