Provider Demographics
NPI:1306133830
Name:MECHAM, PETER JOSEPH
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:MECHAM
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 1:2812 17TH AVE S
Mailing Address - Street 2:STE A
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4048
Mailing Address - Country:US
Mailing Address - Phone:701-775-3101
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0407
Practice Address - Country:US
Practice Address - Phone:352-273-5950
Practice Address - Fax:352-846-3818
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22281223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics