Provider Demographics
NPI:1508959099
Name:PETERSON, PETER J M (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BALLARD DR,
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:860-233-1802
Mailing Address - Fax:
Practice Address - Street 1:625 HOPMEADOW ST.
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070
Practice Address - Country:US
Practice Address - Phone:860-658-5552
Practice Address - Fax:860-651-8569
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT72551223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics