Provider Demographics
NPI:1437436664
Name:JOHN T PETERSON DDS PC
Entity Type:Organization
Organization Name:JOHN T PETERSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-932-3613
Mailing Address - Street 1:200 E COURT ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3843
Mailing Address - Country:US
Mailing Address - Phone:815-932-3613
Mailing Address - Fax:
Practice Address - Street 1:200 E COURT ST
Practice Address - Street 2:SUITE 504
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3843
Practice Address - Country:US
Practice Address - Phone:815-932-3613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A14762122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003311Medicaid
IL606970OtherUNITED CONCORDIA
IL021076OtherFIRST COMMONWEALTH