Provider Demographics
NPI:1568635894
Name:BRIAN R. PETERSON, D.D.S., PC
Entity Type:Organization
Organization Name:BRIAN R. PETERSON, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-325-3368
Mailing Address - Street 1:6812 E BROWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-3757
Mailing Address - Country:US
Mailing Address - Phone:480-325-3368
Mailing Address - Fax:480-325-0718
Practice Address - Street 1:6812 E BROWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3757
Practice Address - Country:US
Practice Address - Phone:480-325-3368
Practice Address - Fax:480-325-0718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty