Provider Demographics
NPI:1417030057
Name:PETERSON, DONALD C JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:C
Last Name:PETERSON
Suffix:JR
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 1:501 12TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241
Mailing Address - Country:US
Mailing Address - Phone:319-351-5439
Mailing Address - Fax:319-354-0491
Practice Address - Street 1:501 12TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241
Practice Address - Country:US
Practice Address - Phone:319-351-5439
Practice Address - Fax:319-354-0491
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry