MEDICARE: MANFRED HENRY PETERS JR. D.D.S.

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	10881	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	89D682	OTHER	TX	BLUE CROSS BLUE SHIELD #
2	B10881-01	OTHER	TX	TEXAS CHIPS

General Provider Information

NPI Number	:	1205919479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANFRED HENRY PETERS JR. D.D.S.

Provider Business Mailing Address
First Line	:	2508 BAY AREA BLVD
Second Line	:	SUITE 100
City	:	HOUSTON
State	:	TX
Zip	:	77058-1531
Country	:	US
Telephone Number	:	281-486-8061
Fax Number	:

Provider Business Practice Location Address
First Line	:	2508 BAY AREA BLVD
Second Line	:	SUITE 100
City	:	HOUSTON
State	:	TX
Zip	:	77058-1531
Country	:	US
Telephone Number	:	281-486-8061
Fax Number	:

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

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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