Healthcare Provider Details

I. General information

NPI: 1285726380
Provider Name (Legal Business Name): JON E PETERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 3RD AVE # SU.201
SAN DIEGO CA
92103-2129
US

IV. Provider business mailing address

4076 3RD AVE # SU.201
SAN DIEGO CA
92103-2129
US

V. Phone/Fax

Practice location:
  • Phone: 619-298-2322
  • Fax:
Mailing address:
  • Phone: 619-298-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number28790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: