MEDICARE: DR. MYSTIE PIETERS 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	122300000X	Dentist	12010411A	IN

General Provider Information

NPI Number	:	1265656243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYSTIE PIETERS DDS

Provider Business Mailing Address
First Line	:	751 E PORTER AVE
Second Line	:	SUITE 1
City	:	CHESTERTON
State	:	IN
Zip	:	46304-9110
Country	:	US
Telephone Number	:	219-929-9289
Fax Number	:

Provider Business Practice Location Address
First Line	:	751 E PORTER AVE
Second Line	:	SUITE 1
City	:	CHESTERTON
State	:	IN
Zip	:	46304-9110
Country	:	US
Telephone Number	:	219-929-9289
Fax Number	:

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	05/02/2016

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