Provider Demographics
NPI:1649373010
Name:PETERSON, WILLIAM ROGER (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROGER
Last Name:PETERSON
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 1:1730 HOLLOWAY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-8547
Mailing Address - Country:US
Mailing Address - Phone:419-865-7433
Mailing Address - Fax:419-865-7860
Practice Address - Street 1:1730 HOLLOWAY RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-8547
Practice Address - Country:US
Practice Address - Phone:419-865-7433
Practice Address - Fax:419-865-7860
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300147061223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics