Provider Demographics
NPI:1114189883
Name:ANDREW M PETERSEN, DDS, LLC
Entity Type:Organization
Organization Name:ANDREW M PETERSEN, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-893-7733
Mailing Address - Street 1:4802 E RAY RD
Mailing Address - Street 2:SUITE #19
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6405
Mailing Address - Country:US
Mailing Address - Phone:480-893-7733
Mailing Address - Fax:
Practice Address - Street 1:4802 E RAY RD
Practice Address - Street 2:SUITE #19
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6405
Practice Address - Country:US
Practice Address - Phone:480-893-7733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty