Provider Demographics
NPI:1699192732
Name:PETERSON, SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 E INNOVATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-1963
Mailing Address - Country:US
Mailing Address - Phone:520-297-2514
Mailing Address - Fax:
Practice Address - Street 1:1830 E INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755
Practice Address - Country:US
Practice Address - Phone:520-297-2514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist