Provider Demographics
NPI:1538289467
Name:PETERSON, GARY JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
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:N7245 US HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:DEERBROOK
Mailing Address - State:WI
Mailing Address - Zip Code:54424-9246
Mailing Address - Country:US
Mailing Address - Phone:715-623-7392
Mailing Address - Fax:
Practice Address - Street 1:2010 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2475
Practice Address - Country:US
Practice Address - Phone:715-623-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33407500Medicaid