Provider Demographics
NPI:1518006147
Name:PETERSON, GARY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
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 1:7241 E ROCKY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 S STONE AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-1914
Practice Address - Country:US
Practice Address - Phone:520-798-3384
Practice Address - Fax:520-791-9311
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice