Provider Demographics
NPI:1609083856
Name:PETERSON, DOUGLAS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
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 1:9 MIDDLETOWN LINCROFT RD
Mailing Address - Street 2:
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1511
Mailing Address - Country:US
Mailing Address - Phone:732-842-5005
Mailing Address - Fax:732-842-8608
Practice Address - Street 1:9 MIDDLETOWN LINCROFT RD
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1511
Practice Address - Country:US
Practice Address - Phone:732-842-5005
Practice Address - Fax:732-842-8608
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1021096001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice