Provider Demographics
NPI:1134325145
Name:PETERSON, MICHAEL W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
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 1:1319 TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590
Mailing Address - Country:US
Mailing Address - Phone:707-552-3160
Mailing Address - Fax:707-552-9532
Practice Address - Street 1:1319 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-552-3160
Practice Address - Fax:707-552-9532
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA229121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice