Provider Demographics
NPI:1164538021
Name:PETERSON, STEPHEN W (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1700
Mailing Address - Country:US
Mailing Address - Phone:231-723-6213
Mailing Address - Fax:231-723-2736
Practice Address - Street 1:206 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1700
Practice Address - Country:US
Practice Address - Phone:231-723-6213
Practice Address - Fax:231-723-2736
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0136941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics