Healthcare Provider Details

I. General information

NPI: 1083821334
Provider Name (Legal Business Name): PETERSON DENTAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 N RANCHO DR
LAS VEGAS NV
89130-3405
US

IV. Provider business mailing address

PO BOX 872710
VANCOUVER WA
98687-2710
US

V. Phone/Fax

Practice location:
  • Phone: 702-313-6868
  • Fax: 702-313-6873
Mailing address:
  • Phone: 360-869-7645
  • Fax: 877-725-7443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADLEY R PETERSON
Title or Position: PC OWNER/PRESIDENT
Credential: DDS
Phone: 360-869-7645