Provider Demographics
NPI:1164552048
Name:PETERSON, DALE ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:ROBERT
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 1:555 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3245
Mailing Address - Country:US
Mailing Address - Phone:307-332-9193
Mailing Address - Fax:
Practice Address - Street 1:555 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3245
Practice Address - Country:US
Practice Address - Phone:307-332-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist