Basic Information
| Provider Information | |||||||||
| NPI: | 1609924190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9943 HICKMAN RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503225304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 E LINN ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALLTOWN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501582901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418446230 | ||||||||
| FaxNumber: | 6418446235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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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 | 1223G0001X | 04721 | IA | Y | Dental Providers | Dentist | General Practice |
No ID Information.