Provider Demographics
NPI:1457486771
Name:PETERSON, ROGER MARTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:MARTIN
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 1:3901 E LAS POSAS ROAD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010
Mailing Address - Country:US
Mailing Address - Phone:805-482-1558
Mailing Address - Fax:805-484-8240
Practice Address - Street 1:3901 E LAS POSAS ROAD
Practice Address - Street 2:SUITE 5
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-482-1558
Practice Address - Fax:805-484-8240
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice