Provider Demographics
NPI:1396978458
Name:PETERSON, ERIC WARREN (DMD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WARREN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HIGROVE PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEEDS
Mailing Address - State:AL
Mailing Address - Zip Code:35094-1700
Mailing Address - Country:US
Mailing Address - Phone:205-699-1155
Mailing Address - Fax:205-699-1159
Practice Address - Street 1:1101 HIGROVE PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:LEEDS
Practice Address - State:AL
Practice Address - Zip Code:35094-1700
Practice Address - Country:US
Practice Address - Phone:205-699-1155
Practice Address - Fax:205-699-1159
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist