Provider Demographics
NPI:1679631253
Name:PETERSON, BRUCE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:L
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 1:1790 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-1934
Mailing Address - Country:US
Mailing Address - Phone:303-659-1064
Mailing Address - Fax:303-659-1065
Practice Address - Street 1:1790 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-1934
Practice Address - Country:US
Practice Address - Phone:303-659-1064
Practice Address - Fax:303-659-1065
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO72271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice