# MARK L. PETERSON

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Peterson Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1467611624
- **Authorized official:** DR. MARK L PETERSON DDS (DENTIST)
- **Authorized official phone:** (208) 745-6536

## Contact information

- **Practice address:** 127 1/2 E SHORT ST, RIGBY, ID 83442-1422
- **Practice address phone:** (208) 745-6536
- **Practice address fax:** (208) 745-0006
- **Mailing address:** 127 1/2 E SHORT ST, RIGBY, ID 83442-1422
- **Mailing address phone:** (208) 745-6536
- **Mailing address fax:** (208) 745-0006

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D1758 | ID | Yes |

## Other

- **Enumeration date:** 06/03/2008
- **Last updated:** 06/03/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 001264500 | — | ID |
| 01 | — | 181636 | IDAHO SMILES | — |
| 01 | — | 476086 | UNITED CONCORDIA | — |