Nathan Michael Peterson, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D-5290 Issued in ID

Practice address

2174 Canyon Plaza Dr Ste 100
Twin Falls, ID 83301-4513

Phone

(208) 735-1415

NPI assigned

Jun 20, 2021

Last updated

May 4, 2025By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in ID

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.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

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

{
    "created_epoch": "1624147200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1746316800000",
    "number": "1114596673",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3842 SUSAN CIR E",
            "city": "HANSEN",
            "state": "ID",
            "postal_code": "833345502",
            "telephone_number": "801-875-1560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2174 CANYON PLAZA DR STE 100",
            "city": "TWIN FALLS",
            "state": "ID",
            "postal_code": "833014513",
            "telephone_number": "208-735-1415"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "NATHAN",
        "middle_name": "MICHAEL",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-06-20",
        "last_updated": "2025-05-04",
        "certification_date": "2025-05-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "ID",
            "license": "D-5290",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kenneth Ryan Petersen, DPT, CSCS
• Scott Trevor Petersen, PHARMD
• Winston N Petersen, PA-C
• Kirk C Peterson, MD
• Kylan D Peterson, D.O.
• Jay Phan
• Seth Phillips, PT
• Sue V. Phillips, D.C.
• Huberta L Phipps, LCPC
• Physician Center , a Professional Company

• General Practice Dentistry in Twin Falls, ID
• Providers in Twin Falls, ID by specialty
• General Practice Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 4, 2025; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.