Provider Demographics
NPI:1720134257
Name:PETERSON, CAROLINE ALSTON (DMD)
Entity type:Individual
Prefix:MISS
First Name:CAROLINE
Middle Name:ALSTON
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5277 COLLEGE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1437
Mailing Address - Country:US
Mailing Address - Phone:510-654-2226
Mailing Address - Fax:
Practice Address - Street 1:5277 COLLEGE AVE STE 203
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1437
Practice Address - Country:US
Practice Address - Phone:510-654-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist