MEDICARE: IAN MICHAEL PEACE

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	DS042197	PA

General Provider Information

NPI Number	:	1285290502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN MICHAEL PEACE

Provider Business Mailing Address
First Line	:	1509 MOUNT ROYAL BLVD
Second Line	:
City	:	GLENSHAW
State	:	PA
Zip	:	15116-2207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1509 MOUNT ROYAL BLVD
Second Line	:
City	:	GLENSHAW
State	:	PA
Zip	:	15116-2207
Country	:	US
Telephone Number	:	412-486-5155
Fax Number	:

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

Provider Enumeration Date	:	05/13/2019
Last Update Date	:	06/23/2019

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Directions to “ IAN MICHAEL PEACE ” Practice Location

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