Provider Demographics
NPI:1558464891
Name:GERALD D. PETERSEN, D.D.S., S.C.
Entity Type:Organization
Organization Name:GERALD D. PETERSEN, D.D.S., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-548-3555
Mailing Address - Street 1:S22 W22660 EAST BROADWAY
Mailing Address - Street 2:STE 2B
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186
Mailing Address - Country:US
Mailing Address - Phone:262-548-3555
Mailing Address - Fax:262-965-2826
Practice Address - Street 1:S22 W22660 EAST BROADWAY
Practice Address - Street 2:STE 2B
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186
Practice Address - Country:US
Practice Address - Phone:262-548-3555
Practice Address - Fax:262-965-2826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty