Healthcare Provider Details

I. General information

NPI: 1821406497
Provider Name (Legal Business Name): CARLY PETERSCHMIDT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 NW PROFESSIONAL DR SUITE 150
CORVALLIS OR
97330-3990
US

IV. Provider business mailing address

850 BOBOLINK AVE
EUGENE OR
97404-1512
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-6587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10080
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: