# LAKE HARBOR DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1639310089
- **Authorized official:** MR. MICHAEL EUGENE PETERSON DDS, PA (PRESIDENT)
- **Authorized official phone:** (208) 853-4687

## Contact information

- **Practice address:** 5355 W STATE ST, BOISE, ID 83703-3333
- **Practice address phone:** (208) 853-4687
- **Practice address fax:** (208) 853-4690
- **Mailing address:** 5355 W STATE ST, BOISE, ID 83703-3333
- **Mailing address phone:** (208) 853-4687
- **Mailing address fax:** (208) 853-4690

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D3044 | ID | Yes |
| 1223G0001X | General Practice Dentistry | D4142 | ID | — |

## Other

- **Enumeration date:** 03/16/2009
- **Last updated:** 03/16/2009