Provider Demographics
NPI:1841350931
Name:PETERSON, MARTI (DDS)
Entity type:Individual
Prefix:MS
First Name:MARTI
Middle Name:
Last Name:PETERSON
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 1:9252 EMERALD LN
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9519
Mailing Address - Country:US
Mailing Address - Phone:716-688-7721
Mailing Address - Fax:716-688-7730
Practice Address - Street 1:1660 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1061
Practice Address - Country:US
Practice Address - Phone:716-688-7721
Practice Address - Fax:716-688-7730
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0496201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02411989Medicaid