Provider Demographics
NPI:1518151992
Name:PETERSON, SCOTT E (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:E
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 1:1809 E PAVILION PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5798
Mailing Address - Country:US
Mailing Address - Phone:970-249-4917
Mailing Address - Fax:
Practice Address - Street 1:1809 E PAVILION PL
Practice Address - Street 2:SUITE A
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5798
Practice Address - Country:US
Practice Address - Phone:970-249-4917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO69431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice