Provider Demographics
NPI:1093444804
Name:PETERSON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11605 DESTINATION DR APT 5404
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4793
Mailing Address - Country:US
Mailing Address - Phone:701-426-9415
Mailing Address - Fax:
Practice Address - Street 1:1927 COLORADO STATE HWY 7
Practice Address - Street 2:SUITE 101
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516
Practice Address - Country:US
Practice Address - Phone:720-874-9039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist