Provider Demographics
NPI:1609924190
Name:PETERSON, ROBERT R (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
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 1:9943 HICKMAN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-5304
Mailing Address - Country:US
Mailing Address - Phone:515-248-1447
Mailing Address - Fax:515-248-1440
Practice Address - Street 1:112 E LINN ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-2901
Practice Address - Country:US
Practice Address - Phone:641-844-6230
Practice Address - Fax:641-844-6235
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA047211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice