Provider Demographics
NPI:1194050617
Name:PETERSON, AUDREY LAUREN (DDS)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LAUREN
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 1:5277 COLLEGE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1437
Mailing Address - Country:US
Mailing Address - Phone:510-654-2226
Mailing Address - Fax:510-595-1455
Practice Address - Street 1:5277 COLLEGE AVE STE 203
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1437
Practice Address - Country:US
Practice Address - Phone:510-654-2226
Practice Address - Fax:510-595-1455
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA584431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice