Provider Demographics
NPI:1306844030
Name:PETERSEN, JAMES G (DMD,PC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:G
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DMD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-2021
Mailing Address - Country:US
Mailing Address - Phone:541-447-3855
Mailing Address - Fax:541-416-9580
Practice Address - Street 1:607 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2021
Practice Address - Country:US
Practice Address - Phone:541-447-3855
Practice Address - Fax:541-416-9580
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD53911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice