Healthcare Provider Details

I. General information

NPI: 1932321858
Provider Name (Legal Business Name): LORIN D. PETERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HARRIS AVE
CLE ELUM WA
98922-0580
US

IV. Provider business mailing address

101 HARRIS AVE P.O. BOX 580
CLE ELUM WA
98922-0580
US

V. Phone/Fax

Practice location:
  • Phone: 509-674-5153
  • Fax: 509-674-7354
Mailing address:
  • Phone: 509-674-5153
  • Fax: 509-674-7354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00005472
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: