Provider Demographics
NPI:1811366198
Name:PETERSON DENTAL, LLC
Entity Type:Organization
Organization Name:PETERSON DENTAL, LLC
Other - Org Name:PETERSON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-699-1155
Mailing Address - Street 1:1101 HIGROVE PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEEDS
Mailing Address - State:AL
Mailing Address - Zip Code:35094-1703
Mailing Address - Country:US
Mailing Address - Phone:205-699-1155
Mailing Address - Fax:205-699-1159
Practice Address - Street 1:1101 HIGROVE PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:LEEDS
Practice Address - State:AL
Practice Address - Zip Code:35094-1703
Practice Address - Country:US
Practice Address - Phone:205-699-1155
Practice Address - Fax:205-699-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-11930OtherBCBS PROVIDER #
1102337492OtherCIGNA GEHA PROVIDER #
AL2586372OtherUNITED CONCORDIA PROVIDER #