Provider Demographics
NPI:1821200015
Name:PETERSON DENTAL GROUP, PC
Entity type:Organization
Organization Name:PETERSON DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PC OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-869-7645
Mailing Address - Street 1:1101 SE TECH CENTER DR STE 195
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5511
Mailing Address - Country:US
Mailing Address - Phone:360-839-7645
Mailing Address - Fax:877-725-7443
Practice Address - Street 1:800 S MEADOWS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-2974
Practice Address - Country:US
Practice Address - Phone:775-851-4646
Practice Address - Fax:775-851-4647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
NV10301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty