Provider Demographics
NPI:1922140292
Name:PETERSON, AIDA N (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:AIDA
Middle Name:N
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16801 NEWBURGH RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1606
Mailing Address - Country:US
Mailing Address - Phone:734-953-6660
Mailing Address - Fax:734-953-1093
Practice Address - Street 1:16801 NEWBURGH RD
Practice Address - Street 2:SUITE 105
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1606
Practice Address - Country:US
Practice Address - Phone:734-953-6660
Practice Address - Fax:734-953-1093
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI137991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics