Provider Demographics
NPI:1134325343
Name:PEDERSEN, PEDER
Entity type:Individual
Prefix:
First Name:PEDER
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 E BERYL AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SPECTRUM HEALTHCARE RESOURCES
Practice Address - Street 2:12647 OLIVE BLVD
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4207122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist