Provider Demographics
NPI:1417246414
Name:PETERSON, JERRY D
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4337
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-4337
Mailing Address - Country:US
Mailing Address - Phone:970-668-4053
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR,
Practice Address - Street 2:SUITE 100
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-4053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist