Provider Demographics
NPI:1396883765
Name:PETERSEN, ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:PETERSEN
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 1:4464 S COBBLESTONE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-4588
Mailing Address - Country:US
Mailing Address - Phone:480-751-7471
Mailing Address - Fax:
Practice Address - Street 1:7400 S POWER RD STE 136
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-9284
Practice Address - Country:US
Practice Address - Phone:480-279-3113
Practice Address - Fax:480-279-2741
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70131223S0112X
PADS0397961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery