MEDICARE: PETERSON LIM D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	63828	CA

General Provider Information

NPI Number	:	1578964110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETERSON LIM D.D.S.

Provider Business Mailing Address
First Line	:	750 N KING RD APT 508
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95133-1555
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	371 JACKLIN RD
Second Line	:
City	:	MILPITAS
State	:	CA
Zip	:	95035-3225
Country	:	US
Telephone Number	:	408-263-2252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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Directions to “ PETERSON LIM D.D.S.” Practice Location

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