Provider Demographics
NPI:1669454096
Name:PETERSEN, PARIS ERNST (DDS)
Entity Type:Individual
Prefix:MR
First Name:PARIS
Middle Name:ERNST
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:PARIS
Other - Middle Name:ERNST
Other - Last Name:MENENDEZ PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8482
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-8482
Mailing Address - Country:US
Mailing Address - Phone:718-932-0946
Mailing Address - Fax:
Practice Address - Street 1:37-53 91ST ST
Practice Address - Street 2:MARCIA D HERRERA DENTISTRY PC
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7901
Practice Address - Country:US
Practice Address - Phone:718-205-4377
Practice Address - Fax:718-205-8605
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0448791122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01471874Medicaid