Provider Demographics
NPI:1225509268
Name:AYLEEN R. PETERSON DDS, INC.
Entity Type:Organization
Organization Name:AYLEEN R. PETERSON DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AYLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-710-7854
Mailing Address - Street 1:4221 SUNNYSLOPE AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3803
Mailing Address - Country:US
Mailing Address - Phone:310-710-7854
Mailing Address - Fax:
Practice Address - Street 1:4221 SUNNYSLOPE AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3803
Practice Address - Country:US
Practice Address - Phone:310-710-7854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty