Individual
DR. SAMUEL PETERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
450 W STATE ST STE 115, EAGLE, ID 83616-7055
(208) 370-5203
(208) 370-5204
Mailing address
450 W STATE ST STE 115, EAGLE, ID 83616-7055
(208) 370-5203
(208) 370-5204
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
10136
KY
1223G0001X
General Practice Dentistry
Primary
D-5038
ID
Other
Enumeration date
06/10/2018
Last updated
02/28/2024
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