Provider Demographics
NPI:1164718201
Name:PETERSON, TERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
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 1:16620 N 40TH ST STE G3
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3351
Mailing Address - Country:US
Mailing Address - Phone:602-953-1850
Mailing Address - Fax:
Practice Address - Street 1:16620 N 40TH ST STE G3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3351
Practice Address - Country:US
Practice Address - Phone:602-953-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist