Individual
MICHAEL E PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
5355 W STATE ST, BOISE, ID 83703-3333
(208) 853-4687
Mailing address
5355 W STATE ST, BOISE, ID 83703-3333
(208) 853-4687
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D-3044
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0027360
—
ID
Enumeration date
04/01/2008
Last updated
04/01/2008
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