Provider Demographics
NPI:1215000666
Name:PETERS, STEVEN R (LICENSE DENTURIST)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:R
Last Name:PETERS
Suffix:
Gender:M
Credentials:LICENSE DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SE OLD OLYMPIC HWY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584
Mailing Address - Country:US
Mailing Address - Phone:360-427-1784
Mailing Address - Fax:360-427-1818
Practice Address - Street 1:3100 SE OLD OLYMPIC HWY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-427-1784
Practice Address - Fax:360-427-1818
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000236122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5040365Medicaid
WA5040365Medicare ID - Type Unspecified