Provider Demographics
NPI:1184044026
Name:PETERSEN, BRIDGET LEIGH
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:LEIGH
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1650
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-0904
Mailing Address - Country:US
Mailing Address - Phone:631-298-5021
Mailing Address - Fax:
Practice Address - Street 1:11535 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-1566
Practice Address - Country:US
Practice Address - Phone:631-298-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058009122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist