Provider Demographics
NPI:1962695015
Name:VENN R. PETERSON, D.D.S., INC.
Entity type:Organization
Organization Name:VENN R. PETERSON, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-459-4420
Mailing Address - Street 1:5024 LACEY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5729
Mailing Address - Country:US
Mailing Address - Phone:360-459-4420
Mailing Address - Fax:360-459-4425
Practice Address - Street 1:5024 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5729
Practice Address - Country:US
Practice Address - Phone:360-459-4420
Practice Address - Fax:360-459-4425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8985122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty