Provider Demographics
NPI:1245300854
Name:PETERSON, WILLIAM HAROLD (DMD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HAROLD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S MERAMEC AVE
Mailing Address - Street 2:STE 923T
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3511
Mailing Address - Country:US
Mailing Address - Phone:314-727-4131
Mailing Address - Fax:314-725-4002
Practice Address - Street 1:225 S MERAMEC AVE
Practice Address - Street 2:STE 923T
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:314-727-4131
Practice Address - Fax:314-725-4002
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0121471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice