Provider Demographics
NPI:1649474677
Name:PETTERSEN, BRUCE VICTOR (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:VICTOR
Last Name:PETTERSEN
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 1:56 BENJAMINS GATE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-8254
Mailing Address - Country:US
Mailing Address - Phone:508-209-0714
Mailing Address - Fax:
Practice Address - Street 1:171 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2222
Practice Address - Country:US
Practice Address - Phone:781-826-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA125281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice