Provider Demographics
NPI:1427534106
Name:PETERSON, LANDON (DDS)
Entity type:Individual
Prefix:DR
First Name:LANDON
Middle Name:
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 1:624 N 129TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-6110
Mailing Address - Country:US
Mailing Address - Phone:023-330-9564
Mailing Address - Fax:402-330-9564
Practice Address - Street 1:624 N 129TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-6110
Practice Address - Country:US
Practice Address - Phone:402-330-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist