Provider Demographics
NPI:1407613425
Name:PETERSON, JACOB DEAN (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DEAN
Last Name:PETERSON
Suffix:
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 1:5000 BLACKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3345
Mailing Address - Country:US
Mailing Address - Phone:307-233-6000
Mailing Address - Fax:307-233-6089
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-233-6000
Practice Address - Fax:307-233-6019
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist