Provider Demographics
NPI:1962746545
Name:PETERSON FAMILY DENTAL PLLC
Entity type:Organization
Organization Name:PETERSON FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-742-6546
Mailing Address - Street 1:240 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-4034
Mailing Address - Country:US
Mailing Address - Phone:603-742-6546
Mailing Address - Fax:603-742-7043
Practice Address - Street 1:240 LOCUST ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-4034
Practice Address - Country:US
Practice Address - Phone:603-742-6546
Practice Address - Fax:603-742-7043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty