Healthcare Provider Details

I. General information

NPI: 1114477692
Provider Name (Legal Business Name): PETERSON DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2983 LONG BEACH RD
OCEANSIDE NY
11572-3204
US

IV. Provider business mailing address

2983 LONG BEACH RD
OCEANSIDE NY
11572-3204
US

V. Phone/Fax

Practice location:
  • Phone: 516-536-5777
  • Fax:
Mailing address:
  • Phone: 516-536-5777
  • Fax: 516-536-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JOHN PETERSON
Title or Position: OFFICER
Credential:
Phone: 516-536-3577