Provider Demographics
NPI:1104131572
Name:PETERMAN, STEPHEN BENJAMIN (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BENJAMIN
Last Name:PETERMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE ROAD BLDG 320, KRUKOWSKI ST
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:TRIPLER AMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5000
Mailing Address - Country:US
Mailing Address - Phone:808-433-1021
Mailing Address - Fax:808-433-3928
Practice Address - Street 1:1 JARRETT WHITE ROAD BLDG 320, KRUKOWSKI ST
Practice Address - Street 2:USA DENTAC
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5000
Practice Address - Country:US
Practice Address - Phone:808-433-1021
Practice Address - Fax:808-433-3928
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6902122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist