Provider Demographics
NPI:1801310008
Name:PETERSON PERIODONTICS & IMPLANTOLOGY LLC
Entity type:Organization
Organization Name:PETERSON PERIODONTICS & IMPLANTOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST, MEMBER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:406-861-8844
Mailing Address - Street 1:4420 SE 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3910
Mailing Address - Country:US
Mailing Address - Phone:406-861-8844
Mailing Address - Fax:
Practice Address - Street 1:5528 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2956
Practice Address - Country:US
Practice Address - Phone:503-788-1008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-29
Last Update Date:2017-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD99051223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty