Provider Demographics
NPI:1174660492
Name:PETTERSEN, ERIC A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:PETTERSEN
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 1:25460 MEDICAL CENTER DR
Mailing Address - Street 2:#200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5985
Mailing Address - Country:US
Mailing Address - Phone:951-677-7322
Mailing Address - Fax:951-677-1860
Practice Address - Street 1:25460 MEDICAL CENTER DR
Practice Address - Street 2:#200
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5985
Practice Address - Country:US
Practice Address - Phone:951-677-7322
Practice Address - Fax:951-677-1860
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0338291223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics