Provider Demographics
NPI:1003498825
Name:PETERSEN, DANIEL BRYCE
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BRYCE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 WOODCREEK FARMS RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-4309
Mailing Address - Country:US
Mailing Address - Phone:540-632-3010
Mailing Address - Fax:
Practice Address - Street 1:1037 WOODCREEK FARMS RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-4309
Practice Address - Country:US
Practice Address - Phone:540-632-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist