Provider Demographics
NPI:1144430679
Name:PETERSON, CHRISTINE GRACE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:GRACE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0204
Mailing Address - Country:US
Mailing Address - Phone:701-258-5253
Mailing Address - Fax:
Practice Address - Street 1:STANDING ROCK IHS HOSPITAL
Practice Address - Street 2:00N10 NORTH RIVER ROAD
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19561223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health