Provider Demographics
NPI:1003170531
Name:PETERSEN, BETHANY ANNE (DDS)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 E RIVERSIDE DR APT 4034
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-1026
Mailing Address - Country:US
Mailing Address - Phone:713-492-7719
Mailing Address - Fax:
Practice Address - Street 1:4410 E RIVERSIDE DR STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-4759
Practice Address - Country:US
Practice Address - Phone:855-512-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28004122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist