Provider Demographics
NPI:1386706448
Name:PETERSON, CARL FREDERICK JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:FREDERICK
Last Name:PETERSON
Suffix:JR
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 1:1200 MCFARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-2312
Mailing Address - Country:US
Mailing Address - Phone:706-861-1828
Mailing Address - Fax:706-861-1936
Practice Address - Street 1:1200 MCFARLAND AVE
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-2312
Practice Address - Country:US
Practice Address - Phone:706-861-1828
Practice Address - Fax:706-861-1936
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADS 8378122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000061685AMedicaid