Provider Demographics
NPI:1104912609
Name:MATHISON, PETER TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:TODD
Last Name:MATHISON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 PAGE DRIVE SOUTH
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3536
Mailing Address - Country:US
Mailing Address - Phone:701-478-4500
Mailing Address - Fax:701-478-4501
Practice Address - Street 1:1351 PAGE DRIVE SOUTH
Practice Address - Street 2:SUITE 102
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3536
Practice Address - Country:US
Practice Address - Phone:701-478-4500
Practice Address - Fax:701-478-4501
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND901933OtherDSC OF ND
MN450484245-00001OtherDELTA DENTAL OF MN