Healthcare Provider Details

I. General information

NPI: 1942604277
Provider Name (Legal Business Name): PETERSON AND ABE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 619-292-2322
  • Fax: 619-298-0679
Mailing address:
  • Phone: 619-292-2322
  • Fax: 619-298-0679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JON PETERSON
Title or Position: PERIODONTIST
Credential: D.D.S.
Phone: 619-298-2322