Provider Demographics
NPI:1013929629
Name:COUPERUS, PETER M (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:COUPERUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2856 ARDEN WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1374
Mailing Address - Country:US
Mailing Address - Phone:916-481-7617
Mailing Address - Fax:916-481-7403
Practice Address - Street 1:2856 ARDEN WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1374
Practice Address - Country:US
Practice Address - Phone:916-481-7617
Practice Address - Fax:916-481-7403
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist