Healthcare Provider Details

I. General information

NPI: 1619413093
Provider Name (Legal Business Name): SCOTT T PETERSON D.M.D. M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5235 W BASELINE RD #187
LAVEEN AZ
85339-3122
US

IV. Provider business mailing address

4216 S MARIPOSA DR
GILBERT AZ
85297-5224
US

V. Phone/Fax

Practice location:
  • Phone: 602-605-8811
  • Fax:
Mailing address:
  • Phone: 480-440-6923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD009577
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: