Provider Demographics
NPI:1700864543
Name:PETERSON, BRANDON KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:KEITH
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 1:6600 WESTOWN PKWY
Mailing Address - Street 2:SUITE 170
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-7707
Mailing Address - Country:US
Mailing Address - Phone:515-223-9700
Mailing Address - Fax:
Practice Address - Street 1:6600 WESTOWN PKWY
Practice Address - Street 2:SUITE 170
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-7707
Practice Address - Country:US
Practice Address - Phone:515-223-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2015-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027419122300000X
IADDS-082881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist