Provider Demographics
NPI:1851492573
Name:PETERSON, THOMAS JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:PETERSON
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 1:519 CHRISTEL DR.
Mailing Address - Street 2:
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245
Mailing Address - Country:US
Mailing Address - Phone:920-775-4531
Mailing Address - Fax:920-775-4180
Practice Address - Street 1:519 CHRISTEL DR.
Practice Address - Street 2:
Practice Address - City:VALDERS
Practice Address - State:WI
Practice Address - Zip Code:54245
Practice Address - Country:US
Practice Address - Phone:920-775-4531
Practice Address - Fax:920-775-4180
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31280151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33456300Medicaid
WI3128015OtherSTATE LICENSE