Provider Demographics
NPI:1588493563
Name:PETERSON, CHRISTIAN (DDS)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:PETERSON
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 1:2743 W PEAK CLOUD LN APT 410
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8862
Mailing Address - Country:US
Mailing Address - Phone:406-750-7640
Mailing Address - Fax:
Practice Address - Street 1:1311 E CENTRAL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7991
Practice Address - Country:US
Practice Address - Phone:406-750-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID30615751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice