Provider Demographics
NPI:1780682526
Name:PETERSON, CANDACE L (DMD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18795 SW BOONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-6807
Mailing Address - Country:US
Mailing Address - Phone:503-691-9046
Mailing Address - Fax:503-692-7229
Practice Address - Street 1:18795 SW BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8412
Practice Address - Country:US
Practice Address - Phone:503-691-9046
Practice Address - Fax:503-692-7229
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2015-03-04
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OR61011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice