Individual
TAYNE PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2200 PARK AVE STE 2, BURLEY, ID 83318-2186
(208) 878-6684
(208) 678-3170
Mailing address
2200 PARK AVE, BURLEY, ID 83318-2186
(208) 878-6684
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D-5401
ID
Other
Enumeration date
06/11/2019
Last updated
09/07/2022
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