Provider Demographics
NPI:1659458602
Name:DORAN, PETER (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:DORAN
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 1:1318 MERIDEN ST
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1030
Mailing Address - Country:US
Mailing Address - Phone:815-539-3000
Mailing Address - Fax:815-539-3733
Practice Address - Street 1:1318 MERIDEN ST
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1030
Practice Address - Country:US
Practice Address - Phone:815-539-3000
Practice Address - Fax:815-539-3733
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice