Healthcare Provider Details

I. General information

NPI: 1659474005
Provider Name (Legal Business Name): MARCUS E PETERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 6TH ST
RUPERT ID
83350-1619
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-650-7941
  • Fax: 208-436-0735
Mailing address:
  • Phone: 208-737-6718
  • Fax: 208-734-5036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8782
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: