Provider Demographics
NPI:1265525943
Name:PETERSON, GREGORY SCOTT (DMD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
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 1:1725 WASHINGTON ROAD
Mailing Address - Street 2:SUITE #505
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15241-2131
Mailing Address - Country:US
Mailing Address - Phone:412-833-3944
Mailing Address - Fax:412-833-4347
Practice Address - Street 1:1725 WASHINGTON ROAD
Practice Address - Street 2:SUITE #505
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15241-2131
Practice Address - Country:US
Practice Address - Phone:412-833-3944
Practice Address - Fax:412-833-4347
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-025423-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice