Jake Allen Peterson, DDS, MD

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

D-5107-OS Issued in ID

Practice address

1475 SW Chandler Ave Ste 101
Bend, OR 97702-3239

Phone

(541) 617-3993

NPI assigned

May 28, 2013

Last updated

Mar 1, 2022By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Previously, effective Sep 13, 2022 through Sep 13, 2026

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• K & L Oms LLC

  • Oral and Maxillofacial Surgery Clinic/Center
  • Bend, OR
  • NPI 1063942043
  NPD
• K & L Oms LLC

  • Oral and Maxillofacial Surgery Clinic/Center
  • Redmond, OR
  • NPI 1598478109
  NPD
• K & L Oms LLC

  • Oral and Maxillofacial Surgery (Dentist)
  • Bend, OR
  • NPI 1619423787
  NPD (past)
• David a Cotant DDS PS

  • Oral and Maxillofacial Surgery (Dentist)
  • Lakewood, WA
  • NPI 1609900638
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1369699200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1646092800000",
    "number": "1043657364",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1475 SW CHANDLER AVE STE 101",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977023239",
            "telephone_number": "541-617-3993"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1475 SW CHANDLER AVE STE 101",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977023239",
            "telephone_number": "541-617-3993"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1475 NE Williamson Blvd",
            "address_purpose": "LOCATION",
            "city": "Bend",
            "state": "OR",
            "postal_code": "977016038",
            "country_code": "US",
            "telephone_number": "541-382-1053",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "JAKE",
        "middle_name": "ALLEN",
        "credential": "DDS, MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2013-05-28",
        "last_updated": "2022-03-01",
        "certification_date": "2022-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "ID",
            "license": "M-15171",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "WA",
            "license": "DE60941667",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "ID",
            "license": "D-5107-OS",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Emily Petersen
• Kiana Kay Shin-Tze Petersen
• Peterson Performance Products Inc (Peterson's Orthotic Lab)
• Peterson Performance Products, Inc. (Foot Fitness)
• Elizabeth Anne Peterson
• Jessica Peterson
• Jodi Peterson
• Johanna Rae Peterson, PA-C
• Lindsey Peterson, PA-C
• Sarah Elizabeth Peterson, LCSW

• Oral and Maxillofacial Surgery (Dentist) in Bend, OR
• Providers in Bend, OR by specialty
• Oral and Maxillofacial Surgery (Dentist) in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.