Provider Demographics
NPI:1396366134
Name:PETERSEN, DANIEL ARTHUR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ARTHUR
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 ALTAMONT RD S APT B12
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2192
Mailing Address - Country:US
Mailing Address - Phone:256-970-5917
Mailing Address - Fax:
Practice Address - Street 1:3350 ALTAMONT RD S APT B12
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2192
Practice Address - Country:US
Practice Address - Phone:256-970-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty