Provider Demographics
NPI:1013134931
Name:PETERSON, DONALD P (DDS, FAGD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:P
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11855 HOLLY LN
Mailing Address - Street 2:SUITE #103
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3114
Mailing Address - Country:US
Mailing Address - Phone:301-645-7585
Mailing Address - Fax:301-843-3367
Practice Address - Street 1:11855 HOLLY LN
Practice Address - Street 2:SUITE #103
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3114
Practice Address - Country:US
Practice Address - Phone:301-645-7585
Practice Address - Fax:301-843-3367
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD91771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice