Provider Demographics
NPI:1386736445
Name:JON E PETERSON D.D.S. , APC
Entity type:Organization
Organization Name:JON E PETERSON D.D.S. , APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-298-2322
Mailing Address - Street 1:4076 3RD AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2129
Mailing Address - Country:US
Mailing Address - Phone:619-298-2322
Mailing Address - Fax:
Practice Address - Street 1:4076 3RD AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2129
Practice Address - Country:US
Practice Address - Phone:619-298-2322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty