Provider Demographics
NPI:1457875700
Name:PETERSON ORTHODONTICS & PERIODONTICS, LLC
Entity Type:Organization
Organization Name:PETERSON ORTHODONTICS & PERIODONTICS, LLC
Other - Org Name:LAKE OSWEGO PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST, MEMBER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:N B
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:909-518-7743
Mailing Address - Street 1:4420 SE 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15962 BOONES FERRY RD STE 108
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4359
Practice Address - Country:US
Practice Address - Phone:503-699-6569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1223P0300X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty