Healthcare Provider Details

I. General information

NPI: 1396978136
Provider Name (Legal Business Name): VALLEY ORAL & FACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 9TH AVE S STE F
FARGO ND
58103-8712
US

IV. Provider business mailing address

2701 9TH AVE S STE F
FARGO ND
58103-8712
US

V. Phone/Fax

Practice location:
  • Phone: 701-772-7379
  • Fax: 701-772-9643
Mailing address:
  • Phone: 701-772-7379
  • Fax: 701-772-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TROY RICHARD PETERSEN
Title or Position: PRESIDENT
Credential: DMD MD
Phone: 701-772-7379