Healthcare Provider Details

I. General information

NPI: 1295647972
Provider Name (Legal Business Name): NATHANIEL J PETERSON DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 TROY RD STE B
EDWARDSVILLE IL
62025-2590
US

IV. Provider business mailing address

837 MADISON AVE
EDWARDSVILLE IL
62025-2323
US

V. Phone/Fax

Practice location:
  • Phone: 630-618-9211
  • Fax:
Mailing address:
  • Phone: 630-618-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. NATHANIEL J PETERSON
Title or Position: DENTIST
Credential: DMD
Phone: 630-618-9211