Provider Demographics
NPI:1427437219
Name:PETERSON, CHRISTOPHER JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JAMES
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 1:3110 GARDENIA DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8520
Mailing Address - Country:US
Mailing Address - Phone:920-740-8761
Mailing Address - Fax:
Practice Address - Street 1:277 N 9TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1548
Practice Address - Country:US
Practice Address - Phone:920-336-6594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001273-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist