Provider Demographics
NPI:1093948614
Name:PETERSON, JONATHAN RYAN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RYAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W CHANDLER BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-2508
Mailing Address - Country:US
Mailing Address - Phone:480-899-6407
Mailing Address - Fax:480-899-2644
Practice Address - Street 1:800 W CHANDLER BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2508
Practice Address - Country:US
Practice Address - Phone:480-899-6407
Practice Address - Fax:480-899-2644
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-30
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist