MEDICARE: LORIN DEAN PETERSON DMD

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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	2803	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699772061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORIN DEAN PETERSON DMD

Provider Business Mailing Address
First Line	:	77 W FOREST AVE
Second Line	:	STE 107
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1482
Country	:	US
Telephone Number	:	928-773-2530
Fax Number	:	928-773-2532

Provider Business Practice Location Address
First Line	:	77 W FOREST AVE
Second Line	:	STE 107
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1482
Country	:	US
Telephone Number	:	928-773-2530
Fax Number	:	928-773-2532

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

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/17/2007

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