Provider Demographics
NPI:1841571387
Name:DAVID A PETO DDS, MSD A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:DAVID A PETO DDS, MSD A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PETO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:310-980-3822
Mailing Address - Street 1:9342 DUXBURY RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-1023
Mailing Address - Country:US
Mailing Address - Phone:310-980-3822
Mailing Address - Fax:
Practice Address - Street 1:9342 DUXBURY RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1023
Practice Address - Country:US
Practice Address - Phone:310-980-3822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54564261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental