Provider Demographics
NPI:1699198663
Name:PETERSEN, LILLIAN (CDL, LD)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CDL, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-0004
Mailing Address - Country:US
Mailing Address - Phone:541-997-6054
Mailing Address - Fax:541-997-6054
Practice Address - Street 1:524 LAUREL STREET
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-0004
Practice Address - Country:US
Practice Address - Phone:541-997-6054
Practice Address - Fax:541-997-6054
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT DO 706283122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122400000XOtherDENTURIST