Search › Idaho › 1223G0001X
Samuel Petersen, DMD
NPI 1720571284 · on the registry since 2018 · sole proprietor
Practice
- Address
- 450 W State St Ste 115
Eagle, ID 83616 - Phone
- (208) 370-5203
- Fax
- (208) 370-5204
- Organisation at this address
- Mrc Llc
Kinesis, Llc
Dan Streeby, D.D.S.
Grange Ophthalmology, Pllc
Grange Surgery Center PllcInferred from a shared address, not stated in the registry. - Clinicians at this address
- 14
Additional practice sites
- 6700 N Linder Rd Ste 132, Meridian, ID
- 6700 N Linder Rd Ste 132, Meridian, ID
Registry record
- Primary taxonomy
- 1223G0001X
1223G0001X
- Also registered as
- 122300000X
- Licence states on file
- KY, ID
From the registry's licence fields, which are often incomplete.
- Sex
- Male
- Record last updated
- 2024-02-28
Source: CMS National Plan and Provider Enumeration System. Registration is not the same as practising, and the registry records no retirement — some people listed here no longer practise. More in Idaho