Provider Demographics
NPI:1285290502
Name:PEACE, IAN MICHAEL
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
Last Name:PEACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 MOUNT ROYAL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENSHAW
Mailing Address - State:PA
Mailing Address - Zip Code:15116-2207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1509 MOUNT ROYAL BLVD
Practice Address - Street 2:
Practice Address - City:GLENSHAW
Practice Address - State:PA
Practice Address - Zip Code:15116-2207
Practice Address - Country:US
Practice Address - Phone:412-486-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS042197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program