Healthcare Provider Details

I. General information

NPI: 1073690889
Provider Name (Legal Business Name): PETER BRENT AMUNDSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 NW HAWTHORNE AVE
BEND OR
97703-2918
US

IV. Provider business mailing address

124 NW HAWTHORNE AVE
BEND OR
97703-2918
US

V. Phone/Fax

Practice location:
  • Phone: 303-521-2916
  • Fax: 541-389-2958
Mailing address:
  • Phone: 303-521-2916
  • Fax: 541-389-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12101
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: