Provider Demographics
NPI:1437324555
Name:JEROME N. PETERSON D.D.S. INC.
Entity Type:Organization
Organization Name:JEROME N. PETERSON D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-557-7744
Mailing Address - Street 1:3620 SOUTH BRISTOL ST
Mailing Address - Street 2:#302
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-9262
Mailing Address - Country:US
Mailing Address - Phone:714-557-7744
Mailing Address - Fax:714-557-1881
Practice Address - Street 1:3620 S BRISTOL ST
Practice Address - Street 2:#302
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7300
Practice Address - Country:US
Practice Address - Phone:714-557-7744
Practice Address - Fax:714-557-1881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23551305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service