MEDICARE: NATHAN MICHAEL PETERSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D-5290	ID

General Provider Information

NPI Number	:	1114596673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN MICHAEL PETERSON DDS

Provider Business Mailing Address
First Line	:	3842 SUSAN CIR E
Second Line	:
City	:	HANSEN
State	:	ID
Zip	:	83334-5502
Country	:	US
Telephone Number	:	801-875-1560
Fax Number	:

Provider Business Practice Location Address
First Line	:	2174 CANYON PLAZA DR STE 100
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4513
Country	:	US
Telephone Number	:	208-735-1415
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2021
Last Update Date	:	05/04/2025

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