Active NPI
Michael E Peterson, DDS
- Dentist
- Boise, ID
National Provider Identifier
1942472691
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- D-3044
- Practice address
- 5355 W State St
Boise, ID 83703-3333 - Phone
- (208) 853-4687
- NPI assigned
- Apr 1, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | D-3044 | ID | Primary |
Addresses
Primary practice location
5355 W State St
Boise, ID 83703-3333
Mailing address
5355 W State St
Boise, ID 83703-3333
Phone (208) 853-4687
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0027360 | Medicaid | ID |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1207008000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1207008000000",
"number": "1942472691",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5355 W STATE ST",
"city": "BOISE",
"state": "ID",
"postal_code": "837033333",
"telephone_number": "208-853-4687"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5355 W STATE ST",
"city": "BOISE",
"state": "ID",
"postal_code": "837033333",
"telephone_number": "208-853-4687"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSON",
"first_name": "MICHAEL",
"middle_name": "E",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-04-01",
"last_updated": "2008-04-01",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "ID",
"license": "D-3044",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0027360",
"state": "ID"
}
],
"endpoints": [],
"other_names": []
}Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.