Provider Demographics
NPI:1801003314
Name:PETERSON, ROBERT KENNETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KENNETH
Last Name:PETERSON
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 1:1644 BARKEI DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-8304
Mailing Address - Country:US
Mailing Address - Phone:847-624-6700
Mailing Address - Fax:
Practice Address - Street 1:2932 FINLEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1042
Practice Address - Country:US
Practice Address - Phone:630-629-6299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0170711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice