Provider Demographics
NPI:1770688756
Name:PETERSON, DOUGLAS BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRUCE
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:PO BOX 400
Mailing Address - Street 2:8470 US HWY 2
Mailing Address - City:IRON RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54847-0400
Mailing Address - Country:US
Mailing Address - Phone:715-372-4407
Mailing Address - Fax:
Practice Address - Street 1:8470 US HWY 2
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:WI
Practice Address - Zip Code:54847-0400
Practice Address - Country:US
Practice Address - Phone:715-372-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3879015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist