Provider Demographics
NPI:1225274442
Name:DANIEL PETERSEN, DDS, INC.
Entity Type:Organization
Organization Name:DANIEL PETERSEN, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-223-1811
Mailing Address - Street 1:2315 BECHELLI LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0119
Mailing Address - Country:US
Mailing Address - Phone:530-223-1811
Mailing Address - Fax:530-223-1813
Practice Address - Street 1:2315 BECHELLI LN
Practice Address - Street 2:SUITE A
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0119
Practice Address - Country:US
Practice Address - Phone:530-223-1811
Practice Address - Fax:530-223-1813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty