Provider Demographics
NPI:1194914218
Name:TYR R. PETERSON, D.D.S., P.C.
Entity type:Organization
Organization Name:TYR R. PETERSON, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYR
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-424-6483
Mailing Address - Street 1:5400 WARD ROAD
Mailing Address - Street 2:BUILDING II, SUITE 100
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-1819
Mailing Address - Country:US
Mailing Address - Phone:303-424-6483
Mailing Address - Fax:
Practice Address - Street 1:5400 WARD ROAD
Practice Address - Street 2:BUILDING II, SUITE 100
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-1819
Practice Address - Country:US
Practice Address - Phone:303-424-6483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7993261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental