Provider Demographics
NPI:1073994752
Name:PETERSEN, ROBERT TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TODD
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 ROYAL OAK CIR
Mailing Address - Street 2:
Mailing Address - City:SPRING CREEK
Mailing Address - State:NV
Mailing Address - Zip Code:89815-7127
Mailing Address - Country:US
Mailing Address - Phone:405-882-9174
Mailing Address - Fax:
Practice Address - Street 1:282 SPRING CREEK PKWY STE 202
Practice Address - Street 2:
Practice Address - City:SPRING CREEK
Practice Address - State:NV
Practice Address - Zip Code:89815-5822
Practice Address - Country:US
Practice Address - Phone:405-882-9174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9429631-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice