Provider Demographics
NPI:1801989975
Name:PETERSON, JOEL BRANDON (DDS)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:BRANDON
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 1:3466 HOLIDAY CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3496
Mailing Address - Country:US
Mailing Address - Phone:563-332-1321
Mailing Address - Fax:563-332-3905
Practice Address - Street 1:3466 HOLIDAY CT
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3496
Practice Address - Country:US
Practice Address - Phone:563-332-1321
Practice Address - Fax:563-332-3905
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA72721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29305OtherBC/BS PROVIDER #
IA637297OtherUNITED CONCORDIA PROVIDER
IA399655Medicaid