Healthcare Provider Details

I. General information

NPI: 1386736445
Provider Name (Legal Business Name): JON E PETERSON D.D.S. , APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 3RD AVE STE 201
SAN DIEGO CA
92103-2129
US

IV. Provider business mailing address

4076 3RD AVE STE 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: DR. JON E PETERSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 619-298-2322