Provider Demographics
NPI:1073608170
Name:PETERSON, MARK A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 BERRY RD
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:FL
Mailing Address - Zip Code:32949-5323
Mailing Address - Country:US
Mailing Address - Phone:321-722-9474
Mailing Address - Fax:
Practice Address - Street 1:7740 BAY ST
Practice Address - Street 2:SUITE # 1
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3427
Practice Address - Country:US
Practice Address - Phone:772-388-3119
Practice Address - Fax:722-388-0250
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00115081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice