Justin Thomas Peterson, D.D.S.
Individual provider Active NPI General Practice Dentistry · Saint Anthony, ID
NPI 1386955029 · NPPES record last updated May 17, 2022
Key facts
- NPI
- 1386955029
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- D4293 (ID)
- Practice address
- 325 E Main St
Saint Anthony, ID 83445-1546 - Phone
- (208) 356-4900
- Fax
- (208) 624-4117
- NPI assigned
- Jun 28, 2010
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D4293 | ID | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Upper Valley Community Health Services Inc | Current |
Accepting new patients | |
| Upper Valley Community Health Services Inc | Past |
Accepting new patients | |
| Eagle Rock Dental Care PLLC | General Practice | Past | Accepting new patients |
| Channing Way Dental Care | General Practice | Past | Accepting new patients |
Locations
72 S 1st E
Ste 102
Rexburg, ID 83440
Phone (208) 356-0100
20 N 3rd E
Saint Anthony, ID 83445
Phone (208) 624-4100
325 E Main St
Saint Anthony, ID 83445
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | D4293 | ID | Yes |
Addresses
Primary practice location
325 E Main St
Saint Anthony, ID 83445-1546
Mailing address
PO Box 18
Saint Anthony, ID 83445-0018
Phone (208) 356-4900
Other practice location 1
72 S 1st E
Rexburg, ID 83440-1902
Phone (208) 356-4900
Other providers in Saint Anthony, ID
- Northfork Developmental Services Inc.
- Scott Nye
- Amy I Ohs
- Richard Palmer
- Tyler Palmer
- Tessa Peterson
- Donald W Powell
- Adam Clay Pruitt
- Erin Michelle Pullman
- Remington Co
All providers in Saint Anthony, ID · General Practice Dentistry in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 17, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.