Provider Demographics
NPI:1720035702
Name:PETERSON, JOHN TERRANCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TERRANCE
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 1:200 EAST COURT STREET
Mailing Address - Street 2:SUITE 504
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3847
Mailing Address - Country:US
Mailing Address - Phone:815-932-3613
Mailing Address - Fax:815-932-5332
Practice Address - Street 1:200 EAST COURT STREET
Practice Address - Street 2:SUITE 504
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3847
Practice Address - Country:US
Practice Address - Phone:815-932-3613
Practice Address - Fax:815-932-5332
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A147621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL021076OtherFIRST COMMONWEALTH
IL606970OtherUNITED CONCORDIA
IL1003311Medicare ID - Type Unspecified