Healthcare Provider Details

I. General information

NPI: 1598673030
Provider Name (Legal Business Name): PETERSON ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 S WASHINGTON AVE STE C
EMMETT ID
83617-3596
US

IV. Provider business mailing address

1312 S WASHINGTON AVE STE C
EMMETT ID
83617-3596
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-6800
  • Fax: 208-365-9600
Mailing address:
  • Phone: 208-365-6800
  • Fax: 208-365-9600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KELSEY PETERSON
Title or Position: OWNER
Credential: DMD, DHSC
Phone: 208-365-6800