Ty Peterson, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D-5035 Issued in ID

Practice address

325 Main St
Gooding, ID 83330-1302

Phone

(208) 934-8080

Fax

(208) 934-9756

NPI assigned

Jun 14, 2019

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1560470400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1560470400000",
    "number": "1689234437",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "325 MAIN ST",
            "city": "GOODING",
            "state": "ID",
            "postal_code": "833301302"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "325 MAIN ST",
            "city": "GOODING",
            "state": "ID",
            "postal_code": "833301302",
            "telephone_number": "208-934-8080",
            "fax_number": "208-934-9756"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "TY",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-06-14",
        "last_updated": "2019-06-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "ID",
            "license": "D-5035",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "Gooding",
            "affiliation": "N",
            "address_1": "325 Main St",
            "city": "Gooding",
            "state": "ID",
            "country_code": "US",
            "postal_code": "833301302",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Erin Orloff
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• Sierra Ann Oyler, PA-C
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• Karen Lee Petty
• Christina Ann Pickett, RDN, LD
• Pro Active Advantage, LLC (Pro Active Behavioral Health)
• Pro Active Advantage, LLC (Pro Active Behavioral Health)
• Pro Active Advantage, LLC (Pro Active Behavioral Health)

• General Practice Dentistry in Gooding, ID
• Providers in Gooding, 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 Jun 14, 2019; 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.