MEDICARE: PETERSON DENTAL GROUP, PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1912114257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON DENTAL GROUP, PC

Provider Business Mailing Address
First Line	:	PO BOX 872710
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98687-2710
Country	:	US
Telephone Number	:	360-869-7645
Fax Number	:	877-725-7443

Provider Business Practice Location Address
First Line	:	3016 W CHARLESTON BLVD
Second Line	:	STE 145
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1977
Country	:	US
Telephone Number	:	702-380-1212
Fax Number	:	702-388-7420

Authorized Official
Title or Position	:	PC OWNER/PRESIDENT
Name	:	DR. BRADLEY R PETERSON
Credential	:	DDS
Telephone Number	:	360-869-7645

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/22/2025

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