Healthcare Provider Details

I. General information

NPI: 1174975429
Provider Name (Legal Business Name): ALAN CLARK PETERSON SR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 MCDONOUGH BLVD SE
ATLANTA GA
30315-4400
US

IV. Provider business mailing address

601 MCDONOUGH BLVD SE
ATLANTA GA
30315-4400
US

V. Phone/Fax

Practice location:
  • Phone: 404-635-5462
  • Fax:
Mailing address:
  • Phone: 404-635-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number015796
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: