Provider Demographics
NPI:1154464998
Name:MICHAEL D PETERSON DDSMSPA
Entity Type:Organization
Organization Name:MICHAEL D PETERSON DDSMSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-754-0400
Mailing Address - Street 1:10301 GEORGIA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-5020
Mailing Address - Country:US
Mailing Address - Phone:301-754-0500
Mailing Address - Fax:301-754-1220
Practice Address - Street 1:10301 GEORGIA AVE STE 202
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5020
Practice Address - Country:US
Practice Address - Phone:301-754-0500
Practice Address - Fax:301-754-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD80041223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty