Individual
DR. MARK EDWARD PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2440 GAYNOR NW, GRAND RAPIDS, MI 49544-1830
(616) 784-8444
(616) 784-6912
Mailing address
2440 GAYNOR NW, GRAND RAPIDS, MI 49544-1830
(616) 784-8444
(616) 784-6912
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
13556
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
124241245
—
MI
01
—
D135560
BLUE CROSS ID
—
Enumeration date
05/24/2006
Last updated
03/14/2019
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