Provider Demographics
NPI:1316430952
Name:PETERSON DENTAL CARE LLC
Entity type:Organization
Organization Name:PETERSON DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-780-9964
Mailing Address - Street 1:1700 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2260
Mailing Address - Country:US
Mailing Address - Phone:630-780-9964
Mailing Address - Fax:
Practice Address - Street 1:2501 W ILES AVE STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6482
Practice Address - Country:US
Practice Address - Phone:217-787-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029045261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental