Provider Demographics
NPI:1013575430
Name:PETERSON, ADEN (DDS)
Entity Type:Individual
Prefix:
First Name:ADEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 EMERY ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-4508
Mailing Address - Country:US
Mailing Address - Phone:802-922-6547
Mailing Address - Fax:
Practice Address - Street 1:1015 S TAFT HILL RD STE K
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-4240
Practice Address - Country:US
Practice Address - Phone:970-980-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14239122300000X
CODEN.00205199122300000X
IARES-30579390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist