Provider Demographics
NPI:1225480999
Name:PETERSON, CLEA (RDH)
Entity type:Individual
Prefix:
First Name:CLEA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 MIL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEWIS
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:253-966-9960
Mailing Address - Fax:
Practice Address - Street 1:9119 MIL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:FORT LEWIS
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-966-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000905422124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist