Provider Demographics
NPI:1467233510
Name:PETERS, FATIMAH
Entity Type:Individual
Prefix:
First Name:FATIMAH
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 S 58TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-4526
Mailing Address - Country:US
Mailing Address - Phone:267-324-9297
Mailing Address - Fax:
Practice Address - Street 1:5000 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5137
Practice Address - Country:US
Practice Address - Phone:888-296-4772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH075442124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist