Healthcare Provider Details

I. General information

NPI: 1205994373
Provider Name (Legal Business Name): BRYAN JAMES PETERSEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N A ST
GRANGEVILLE ID
83530-1211
US

IV. Provider business mailing address

216 S COLLEGE ST
GRANGEVILLE ID
83530-1922
US

V. Phone/Fax

Practice location:
  • Phone: 208-983-1651
  • Fax:
Mailing address:
  • Phone: 208-983-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-3101
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: