Provider Demographics
NPI:1578642559
Name:PETERSON-HOULE, GEORGIA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGIA
Middle Name:MARIE
Last Name:PETERSON-HOULE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:GEORGIA
Other - Middle Name:MARIE
Other - Last Name:PETERSON HOULE PA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:20470 N LAKE PLEASANT RD # 1100
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9708
Mailing Address - Country:US
Mailing Address - Phone:602-992-1486
Mailing Address - Fax:
Practice Address - Street 1:20470 N LAKE PLEASANT RD STE 110
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9708
Practice Address - Country:US
Practice Address - Phone:602-992-1486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0117251223S0112X, 1223G0001X, 1223S0112X
AZD0017251223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN310422200Medicaid