Healthcare Provider Details

I. General information

NPI: 1215410584
Provider Name (Legal Business Name): DAVID PETERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 BRANDYWINE LN
DIXON IL
61021-8757
US

IV. Provider business mailing address

1619 BRANDYWINE LN
DIXON IL
61021-8757
US

V. Phone/Fax

Practice location:
  • Phone: 815-622-4740
  • Fax:
Mailing address:
  • Phone: 815-622-4740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021001236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: