Provider Demographics
NPI:1952520710
Name:PETERSON, DOUGLAS DON (DDS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DON
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 1:2411 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3128
Mailing Address - Country:US
Mailing Address - Phone:561-966-9557
Mailing Address - Fax:561-966-5886
Practice Address - Street 1:2411 10TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3128
Practice Address - Country:US
Practice Address - Phone:561-966-9557
Practice Address - Fax:561-966-5886
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL99301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice