Provider Demographics
NPI:1619534542
Name:PETERSON, ISAAC (DDS)
Entity Type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:
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 1:1413 MEADOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-0813
Mailing Address - Country:US
Mailing Address - Phone:801-634-1966
Mailing Address - Fax:
Practice Address - Street 1:1413 MEADOW RUN DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-0813
Practice Address - Country:US
Practice Address - Phone:801-634-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7196122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty