Provider Demographics
NPI:1932321858
Name:PETERSON, LORIN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:LORIN
Middle Name:D
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 1:101 HARRIS AVE
Mailing Address - Street 2:P.O. BOX 580
Mailing Address - City:CLE ELUM
Mailing Address - State:WA
Mailing Address - Zip Code:98922-0580
Mailing Address - Country:US
Mailing Address - Phone:509-674-5153
Mailing Address - Fax:509-674-7354
Practice Address - Street 1:101 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:CLE ELUM
Practice Address - State:WA
Practice Address - Zip Code:98922-0580
Practice Address - Country:US
Practice Address - Phone:509-674-5153
Practice Address - Fax:509-674-7354
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000054721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5775002Medicaid