Provider Demographics
NPI:1104944537
Name:SODERSTROM, PETER THOMAS (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:THOMAS
Last Name:SODERSTROM
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 TIMOTHY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4419
Mailing Address - Country:US
Mailing Address - Phone:209-544-0404
Mailing Address - Fax:209-544-1008
Practice Address - Street 1:1605 TIMOTHY AVE STE A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4419
Practice Address - Country:US
Practice Address - Phone:209-544-0404
Practice Address - Fax:209-544-1008
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA368351223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics