Healthcare Provider Details

I. General information

NPI: 1376806224
Provider Name (Legal Business Name): JAMES PETERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W ILES AVE STE A
SPRINGFIELD IL
62704-6482
US

IV. Provider business mailing address

2501 W ILES AVE STE A
SPRINGFIELD IL
62704-6482
US

V. Phone/Fax

Practice location:
  • Phone: 217-452-3057
  • Fax:
Mailing address:
  • Phone: 217-452-3057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019029045
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019029045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: