Provider Demographics
NPI:1811373350
Name:PETERKIN, JESSICA BRERETON (DMD, MA)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:BRERETON
Last Name:PETERKIN
Suffix:
Gender:F
Credentials:DMD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13856 W WADDELL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-3801
Mailing Address - Country:US
Mailing Address - Phone:623-544-8353
Mailing Address - Fax:
Practice Address - Street 1:13856 W WADDELL RD STE 102
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-3801
Practice Address - Country:US
Practice Address - Phone:623-544-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist