Provider Demographics
NPI:1497817191
Name:PETERSEN, DANIEL W (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:W
Last Name:PETERSEN
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 1:316 KNOLLCREST DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0104
Mailing Address - Country:US
Mailing Address - Phone:530-223-1811
Mailing Address - Fax:530-223-1813
Practice Address - Street 1:316 KNOLLCREST DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0104
Practice Address - Country:US
Practice Address - Phone:530-223-1811
Practice Address - Fax:530-223-1813
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050824122300000X
CA570311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist