Healthcare Provider Details

I. General information

NPI: 1396883765
Provider Name (Legal Business Name): ANDREW PETERSEN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 S POWER RD STE 136
GILBERT AZ
85297-9284
US

IV. Provider business mailing address

4464 S COBBLESTONE ST
GILBERT AZ
85297-4588
US

V. Phone/Fax

Practice location:
  • Phone: 480-279-3113
  • Fax: 480-279-2741
Mailing address:
  • Phone: 480-751-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7013
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: