Healthcare Provider Details

I. General information

NPI: 1912016866
Provider Name (Legal Business Name): RICHARD C PETERS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 HWY 50
PECOS NM
87552-0710
US

IV. Provider business mailing address

PO BOX 710 199HWY 50
PECOS NM
87552-0710
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-6666
  • Fax: 505-757-2700
Mailing address:
  • Phone: 505-757-6666
  • Fax: 505-757-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1335
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: