Provider Demographics
NPI:1720159080
Name:PETERSON, BENJAMIN T (DDS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:T
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 1:271 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4530
Mailing Address - Country:US
Mailing Address - Phone:541-889-9407
Mailing Address - Fax:541-889-6551
Practice Address - Street 1:271 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4530
Practice Address - Country:US
Practice Address - Phone:541-889-9407
Practice Address - Fax:541-889-6551
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD84131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231468Medicaid