Provider Demographics
NPI:1972683340
Name:PETERSON, MATTHEW C (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 SWIFT RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-6433
Mailing Address - Country:US
Mailing Address - Phone:941-926-7726
Mailing Address - Fax:941-926-7728
Practice Address - Street 1:4729 SWIFT RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-6433
Practice Address - Country:US
Practice Address - Phone:941-926-7726
Practice Address - Fax:941-926-7728
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00124581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice