Justin Thomas Peterson, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D4293 Issued in 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

Last updated

May 17, 2022By 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

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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.

• Upper Valley Community Health Services Inc

  dba Grand Peaks Dental

  • Federally Qualified Health Center (FQHC)
  • Saint Anthony, ID
  • NPI 1053770230
  NPD
• Channing Way Dental Care

  • General Practice Dentistry
  • Idaho Falls, ID
  • NPI 1376555292
  NPD (past)
• Eagle Rock Dental Care PLLC

  • General Practice Dentistry
  • Idaho Falls, ID
  • NPI 1326395385
  NPD (past)
• Upper Valley Community Health Services Inc

  dba Grand Peaks Dental

  • Federally Qualified Health Center (FQHC)
  • Rexburg, ID
  • NPI 1558123356
  NPD (past)

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

{
    "created_epoch": "1277683200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1652745600000",
    "number": "1386955029",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 18",
            "city": "SAINT ANTHONY",
            "state": "ID",
            "postal_code": "834450018",
            "telephone_number": "208-356-4900",
            "fax_number": "208-624-4117"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "325 E MAIN ST",
            "city": "SAINT ANTHONY",
            "state": "ID",
            "postal_code": "834451546",
            "telephone_number": "208-356-4900",
            "fax_number": "208-624-4117"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "72 S 1st E",
            "address_purpose": "LOCATION",
            "city": "Rexburg",
            "state": "ID",
            "postal_code": "834401902",
            "country_code": "US",
            "telephone_number": "208-356-4900",
            "fax_number": "208-356-3724",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "JUSTIN",
        "middle_name": "THOMAS",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-06-28",
        "last_updated": "2022-05-17",
        "certification_date": "2022-05-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "ID",
            "license": "D4293",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Northfork Developmental Services Inc.
• Scott Nye
• Amy I Ohs, LCSW
• Richard Palmer, LPC
• Tyler Palmer, PTA
• Tessa Peterson, LMSW
• Donald W Powell, LMT
• Adam Clay Pruitt
• Erin Michelle Pullman, LCSW
• Remington Co (Kindred Speech and Language)

• General Practice Dentistry in Saint Anthony, ID
• Providers in Saint Anthony, 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 17, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.