Provider Demographics
NPI:1437283165
Name:PETERSON, ROYCE T (DMD)
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:T
Last Name:PETERSON
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 1:3100 N WEST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1651
Mailing Address - Country:US
Mailing Address - Phone:928-779-0331
Mailing Address - Fax:
Practice Address - Street 1:3100 N WEST ST STE 100
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1651
Practice Address - Country:US
Practice Address - Phone:928-779-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6624122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist