Healthcare Provider Details

I. General information

NPI: 1639638265
Provider Name (Legal Business Name): MARK E PETERSON, DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 GAYNOR AVE NW
GRAND RAPIDS MI
49544-1830
US

IV. Provider business mailing address

2440 GAYNOR AVE NW
GRAND RAPIDS MI
49544-1830
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-8444
  • Fax: 616-784-6912
Mailing address:
  • Phone: 616-784-8444
  • Fax: 616-784-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARK PETERSON
Title or Position: DENTIST
Credential: DDS
Phone: 616-784-8444