Basic Information
| Provider Information | |||||||||
| NPI: | 1225569916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 GREENVALE LN | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074776612 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2448 GUERNEVILLE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954034175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075792808 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 03/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 101238 | CA | Y | Dental Providers | Dentist |
No ID Information.