Provider Demographics
NPI:1093734865
Name:PETERSON, WILLIAM J (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:PETERSON
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 1:275 N MAIN ST
Mailing Address - Street 2:BOX 378
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-1840
Mailing Address - Country:US
Mailing Address - Phone:402-376-1942
Mailing Address - Fax:402-376-1835
Practice Address - Street 1:275 N MAIN ST
Practice Address - Street 2:BOX 378
Practice Address - City:VALENTINE
Practice Address - State:NE
Practice Address - Zip Code:69201-1840
Practice Address - Country:US
Practice Address - Phone:402-376-1942
Practice Address - Fax:402-376-1835
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE48691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE4963OtherBLUE CROSS BLUE SHIELD
NE47-0641404-00Medicaid