Provider Demographics
NPI:1437311370
Name:PETERSON, GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
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 1:400 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 708
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7601
Mailing Address - Country:US
Mailing Address - Phone:310-266-5944
Mailing Address - Fax:
Practice Address - Street 1:503 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821
Practice Address - Country:US
Practice Address - Phone:310-266-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist