Provider Demographics
NPI:1013073568
Name:CHEN, PETER S (DMD, MMSC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:CHEN
Suffix:
Gender:M
Credentials:DMD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 JOHNS LAKE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7005
Mailing Address - Country:US
Mailing Address - Phone:617-784-1970
Mailing Address - Fax:
Practice Address - Street 1:1471 JOHNS LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:617-784-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202561223E0200X
FL177941223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11812OtherBLUE CROSS & BLUE SHIELD
FL1942689807OtherNPI TYPE 2