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General NPI Number Information
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NPI Number | 1760626857
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Entity Type | Organization
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Legal Business Name | FACIAL DIMENSIONS, P.C.
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Dates
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Enumeration Date | 04/21/2009
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Last Update Date | 04/21/2009
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Provider Practice Location Address
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Address Line | 710 W KOENIG ST
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City | GRAND ISLAND
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State | NE
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Zip | 68801-6556
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Country | US
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Telephone | 308-384-1172
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Fax |
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Provider Business Mailing Address
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Address Line | 710 W KOENIG ST
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City | GRAND ISLAND
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State | NE
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Zip | 68801-6556
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Country | US
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Telephone | 308-384-1172
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | G A. PETERSON
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Credential | D.D.S., M.D.
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Telephone | 308-384-1172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 4372
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License Number State | NE
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