Provider Demographics
NPI:1083673271
Name:PETERSEN, DANIEL ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ALLEN
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 1:7223 W CLEARWATER AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-783-8822
Mailing Address - Fax:509-783-1983
Practice Address - Street 1:7223 W CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-783-8822
Practice Address - Fax:509-783-1983
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000063311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
5871PEOtherBLUE CROSS
685412OtherUNITED CONCORDIA
75693OtherWDS DELTA
WA5012711Medicaid