Provider Demographics
NPI:1952960205
Name:PETERSON, TAYNE
Entity type:Individual
Prefix:
First Name:TAYNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2186
Mailing Address - Country:US
Mailing Address - Phone:208-878-6684
Mailing Address - Fax:
Practice Address - Street 1:2200 PARK AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2186
Practice Address - Country:US
Practice Address - Phone:208-878-6684
Practice Address - Fax:208-678-3170
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-54011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice