Provider Demographics
NPI:1710903299
Name:PETTERSEN, ERIC (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:PETTERSEN
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:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-0788
Mailing Address - Country:US
Mailing Address - Phone:928-567-5249
Mailing Address - Fax:928-567-0430
Practice Address - Street 1:522 W FINNIE FLATS RD
Practice Address - Street 2:STE J
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-5249
Practice Address - Fax:928-567-0430
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice