Provider Demographics
NPI:1831980473
Name:PETERSON ORTHODONTICS LLC
Entity type:Organization
Organization Name:PETERSON ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:402-330-9564
Mailing Address - Street 1:624 N 129TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-6110
Mailing Address - Country:US
Mailing Address - Phone:402-330-9564
Mailing Address - Fax:402-330-9564
Practice Address - Street 1:624 N 129TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-6110
Practice Address - Country:US
Practice Address - Phone:402-330-9564
Practice Address - Fax:402-330-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10029018000Medicaid