Provider Demographics
NPI:1578799375
Name:PETERSON, WILLIAM DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
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 1:1803 VLG GREEN BLVD APT 104
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6109
Mailing Address - Country:US
Mailing Address - Phone:616-724-0412
Mailing Address - Fax:810-232-1054
Practice Address - Street 1:2811 E COURT ST
Practice Address - Street 2:SUITE I
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506-4054
Practice Address - Country:US
Practice Address - Phone:810-232-2920
Practice Address - Fax:810-232-1054
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist