Provider Demographics
NPI:1871901371
Name:PETERSCHMIDT, TYLER (DMD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:PETERSCHMIDT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BOBOLINK AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-1512
Mailing Address - Country:US
Mailing Address - Phone:541-905-4116
Mailing Address - Fax:
Practice Address - Street 1:4120 QUEST DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-8768
Practice Address - Country:US
Practice Address - Phone:541-688-7278
Practice Address - Fax:541-334-6604
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice