Provider Demographics
NPI:1518072172
Name:PETERSON, LARRY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
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 1:1234 19TH ST NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-2407
Mailing Address - Country:US
Mailing Address - Phone:202-785-0555
Mailing Address - Fax:202-785-5566
Practice Address - Street 1:1234 19TH ST NW
Practice Address - Street 2:SUITE 200
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-2407
Practice Address - Country:US
Practice Address - Phone:202-785-0555
Practice Address - Fax:202-785-5566
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2842OtherDISTRICT OF COLUMBIA
2842OtherDISTRICT OF COLUMBIA