Provider Demographics
NPI:1912538810
Name:VANESSA PETERSON, DDS, MS, PC
Entity Type:Organization
Organization Name:VANESSA PETERSON, DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-774-0107
Mailing Address - Street 1:10165 FOOTHILL BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0341
Mailing Address - Country:US
Mailing Address - Phone:097-740-1079
Mailing Address - Fax:
Practice Address - Street 1:10165 FOOTHILL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0341
Practice Address - Country:US
Practice Address - Phone:909-774-0107
Practice Address - Fax:909-774-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty