Provider Demographics
NPI:1679635056
Name:PETERSON, VENN R (DDS)
Entity Type:Individual
Prefix:
First Name:VENN
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 1:5024 LACEY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5729
Mailing Address - Country:US
Mailing Address - Phone:360-459-4420
Mailing Address - Fax:360-453-4425
Practice Address - Street 1:5024 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5729
Practice Address - Country:US
Practice Address - Phone:360-459-4420
Practice Address - Fax:360-453-4425
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA89851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice