Provider Demographics
NPI:1841496650
Name:PECKHAM, LON NORMAN (DMD)
Entity type:Individual
Prefix:DR
First Name:LON
Middle Name:NORMAN
Last Name:PECKHAM
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 1:351 MOOSE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-9265
Mailing Address - Country:US
Mailing Address - Phone:855-553-7566
Mailing Address - Fax:
Practice Address - Street 1:801 E MEDICAL CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7298
Practice Address - Country:US
Practice Address - Phone:855-553-7566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60576227122300000X
IDD1901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist