Provider Demographics
NPI:1376806224
Name:PETERSON, JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 1:331 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:IL
Mailing Address - Zip Code:62691-1571
Mailing Address - Country:US
Mailing Address - Phone:217-452-3057
Mailing Address - Fax:
Practice Address - Street 1:331 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:IL
Practice Address - Zip Code:62691-1571
Practice Address - Country:US
Practice Address - Phone:217-452-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190290451223G0001X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019029045OtherILLINOIS LICENSE NUMBER