Healthcare Provider Details

I. General information

NPI: 1104912609
Provider Name (Legal Business Name): PETER TODD MATHISON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 PAGE DRIVE SOUTH SUITE 102
FARGO ND
58103-3536
US

IV. Provider business mailing address

1351 PAGE DRIVE SOUTH SUITE 102
FARGO ND
58103-3536
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-4500
  • Fax: 701-478-4501
Mailing address:
  • Phone: 701-478-4500
  • Fax: 701-478-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1933
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: