Provider Demographics
NPI:1134309628
Name:PETERSON, MONICA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 N AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:608 B STREET WEST
Practice Address - Street 2:
Practice Address - City:RAINIER
Practice Address - State:OR
Practice Address - Zip Code:97048
Practice Address - Country:US
Practice Address - Phone:503-556-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist