Provider Demographics
NPI:1083844161
Name:PETERSON, THOMAS LAWRENCE
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LAWRENCE
Last Name:PETERSON
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 1:2225 DOROTHY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1943
Mailing Address - Country:US
Mailing Address - Phone:478-318-0129
Mailing Address - Fax:
Practice Address - Street 1:501 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1701
Practice Address - Country:US
Practice Address - Phone:502-852-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist