Provider Demographics
NPI:1073615993
Name:PETERMAN, MICHAEL SCOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:PETERMAN
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 1:2817 REILLY ST STOP B
Mailing Address - Street 2:USA DENTAL ACTIVITY MCDS NA B
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7302
Mailing Address - Country:US
Mailing Address - Phone:910-396-5610
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST STOP B
Practice Address - Street 2:USA DENTAL ACTIVITY MCDS NA B
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7302
Practice Address - Country:US
Practice Address - Phone:910-396-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist