Provider Demographics
NPI:1942604277
Name:PETERSON AND ABE
Entity Type:Organization
Organization Name:PETERSON AND ABE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-298-2322
Mailing Address - Street 1:4076 3RD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2129
Mailing Address - Country:US
Mailing Address - Phone:619-292-2322
Mailing Address - Fax:619-298-0679
Practice Address - Street 1:4076 3RD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2129
Practice Address - Country:US
Practice Address - Phone:619-292-2322
Practice Address - Fax:619-298-0679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty