Provider Demographics
NPI:1437348109
Name:PETERSON, GARY R (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 MAIN ST
Mailing Address - Street 2:SUITE C 1
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3222
Mailing Address - Country:US
Mailing Address - Phone:508-759-2721
Mailing Address - Fax:508-759-6216
Practice Address - Street 1:258 MAIN ST
Practice Address - Street 2:SUITE C 1
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-3222
Practice Address - Country:US
Practice Address - Phone:508-759-2721
Practice Address - Fax:508-759-6216
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA38-768OtherHARVARD PILGRIM HTHCARE
MA441OtherDELTA DENTAL OF MA
MAX11460OtherBLUE CROSS BLUE SHIELD
MA711889OtherUNITED CONCORDIA