Provider Demographics
NPI:1225197841
Name:PETERSON, STEPHAN L (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:L
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 1:240 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820
Mailing Address - Country:US
Mailing Address - Phone:603-742-6546
Mailing Address - Fax:603-742-7043
Practice Address - Street 1:240 LOCUST ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820
Practice Address - Country:US
Practice Address - Phone:603-742-6546
Practice Address - Fax:603-742-7043
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH17251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0202034Y0NH01OtherFED BC BS
NH89192034Medicaid
ME139950000OtherMAINE CARE