Healthcare Provider Details

I. General information

NPI: 1669614772
Provider Name (Legal Business Name): JOHN A. BIERLY DMD AND PETER J. PETERSON DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W AVON RD
AVON CT
06001-3677
US

IV. Provider business mailing address

20 W AVON RD
AVON CT
06001-3677
US

V. Phone/Fax

Practice location:
  • Phone: 860-404-0233
  • Fax:
Mailing address:
  • Phone: 860-404-0233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7255
License Number StateCT

VIII. Authorized Official

Name: PETER PETERSON
Title or Position: PARTNER
Credential:
Phone: 860-677-8747