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General NPI Number Information
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NPI Number | 1598673030
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Entity Type | Organization
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Legal Business Name | PETERSON ORTHODONTICS PLLC
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Dates
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Enumeration Date | 08/27/2026
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Last Update Date | 08/27/2026
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Provider Practice Location Address
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Address Line | 1312 S WASHINGTON AVE STE C
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City | EMMETT
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State | ID
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Zip | 83617-3596
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Country | US
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Telephone | 208-365-6800
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Fax | 208-365-9600
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Provider Business Mailing Address
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Address Line | 1312 S WASHINGTON AVE STE C
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City | EMMETT
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State | ID
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Zip | 83617-3596
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Country | US
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Telephone | 208-365-6800
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Fax | 208-365-9600
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Authorized Official
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Title or Position | OWNER
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Name | KELSEY PETERSON
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Credential | DMD, DHSC
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Telephone | 208-365-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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