Healthcare Provider Details

I. General information

NPI: 1093133696
Provider Name (Legal Business Name): VALLEY ORAL & FACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 S COLUMBIA RD STE C
GRAND FORKS ND
58201-4007
US

IV. Provider business mailing address

3187 BLUESTEM DR STE 4
WEST FARGO ND
58078-8008
US

V. Phone/Fax

Practice location:
  • Phone: 701-772-7379
  • Fax: 701-772-9643
Mailing address:
  • Phone: 701-235-7379
  • Fax: 701-235-0977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. TROY RICHARD PETERSEN
Title or Position: PRESIDENT
Credential: DMD MD
Phone: 70017727379