Provider Demographics
NPI:1750373197
Name:PASTRELL, PETER DARRELL (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:DARRELL
Last Name:PASTRELL
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 1:350 MERIDIAN WAY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5813
Mailing Address - Country:US
Mailing Address - Phone:541-476-4199
Mailing Address - Fax:
Practice Address - Street 1:350 MERIDIAN WAY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5813
Practice Address - Country:US
Practice Address - Phone:541-476-4199
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD72771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice