Provider Demographics
NPI:1215249917
Name:PETERSEN, MATHEW C (DDS)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:C
Last Name:PETERSEN
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 1:2001 E LOHMAN AVE
Mailing Address - Street 2:STE 121
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3167
Mailing Address - Country:US
Mailing Address - Phone:575-527-4746
Mailing Address - Fax:575-524-7646
Practice Address - Street 1:2001 E LOHMAN AVE
Practice Address - Street 2:STE 121
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3167
Practice Address - Country:US
Practice Address - Phone:575-527-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD33301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice