Provider Demographics
NPI:1790031128
Name:PETERSEN, GRANT DEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:DEE
Last Name:PETERSEN
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 1:1060 GAFFNEY RD STOP 7500
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:580-442-4002
Practice Address - Street 1:1060 GAFFNEY RD STOP 7500
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5007
Practice Address - Country:US
Practice Address - Phone:907-353-5530
Practice Address - Fax:317-361-5530
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00201800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist