Provider Demographics
NPI:1770968422
Name:PETERSON, SAVANNA M (DMD)
Entity type:Individual
Prefix:
First Name:SAVANNA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SAVANNA
Other - Middle Name:M
Other - Last Name:KIRLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1462 W GRANADA BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1462 W GRANADA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9167
Practice Address - Country:US
Practice Address - Phone:386-675-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 214791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice