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General NPI Number Information
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NPI Number | 1801310008
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Entity Type | Organization
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Legal Business Name | PETERSON PERIODONTICS & IMPLANTOLOGY LLC
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Dates
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Enumeration Date | 07/29/2017
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Last Update Date | 07/29/2017
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Provider Practice Location Address
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Address Line | 5528 SE POWELL BLVD
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City | PORTLAND
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State | OR
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Zip | 97206-2956
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Country | US
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Telephone | 503-788-1008
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Fax |
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Provider Business Mailing Address
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Address Line | 4420 SE 51ST AVE
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City | PORTLAND
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State | OR
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Zip | 97206-3910
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Country | US
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Telephone | 406-861-8844
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Fax |
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Authorized Official
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Title or Position | PERIODONTIST, MEMBER OF LLC
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Name | DR. ANDREW GREGORY PETERSON
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Credential | DMD, MS
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Telephone | 406-861-8844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D9905
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License Number State | OR
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