Provider Demographics
NPI:1922012061
Name:PETERSON, EDWIN ROY (DDS)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:ROY
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 1:629 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3555
Mailing Address - Country:US
Mailing Address - Phone:417-667-3134
Mailing Address - Fax:
Practice Address - Street 1:629 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3555
Practice Address - Country:US
Practice Address - Phone:417-667-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist