MEDICARE: DR. NICHOLAS JAMES PETERSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6258421-9921	UT

General Provider Information

NPI Number	:	1639281363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS JAMES PETERSON DMD

Provider Business Mailing Address
First Line	:	PSC 557 BOX 2963
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96379
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	PSC 557 BOX 2963
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96379
Country	:	US
Telephone Number	:	6456381
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	04/20/2008

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