Basic Information
| Provider Information | |||||||||
| NPI: | 1811366198 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSON DENTAL, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PETERSON DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 HIGROVE PKWY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LEEDS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350941703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056991155 | ||||||||
| FaxNumber: | 2056991159 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 HIGROVE PKWY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LEEDS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350941703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056991155 | ||||||||
| FaxNumber: | 2056991159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2015 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2056991155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5696 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 511-11930 | 01 | AL | BCBS PROVIDER # | OTHER | 1102337492 | 01 | CIGNA GEHA PROVIDER # | OTHER | 2586372 | 01 | AL | UNITED CONCORDIA PROVIDER # | OTHER |