Healthcare Provider Details

I. General information

NPI: 1407577844
Provider Name (Legal Business Name): ALEXANDER GREGORY O'NEAL PETERSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11160 HIGHWAY 62
EAGLE POINT OR
97524-8025
US

IV. Provider business mailing address

1221 DISK DR
MEDFORD OR
97501-6638
US

V. Phone/Fax

Practice location:
  • Phone: 541-500-0763
  • Fax:
Mailing address:
  • Phone: 458-658-5930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11692
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: