Healthcare Provider Details

I. General information

NPI: 1164599791
Provider Name (Legal Business Name): STEVEN D. PETERSON D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S GAMMON RD STE. 150
MADISON WI
53717-1400
US

IV. Provider business mailing address

202 S GAMMON RD STE. 150
MADISON WI
53717-1400
US

V. Phone/Fax

Practice location:
  • Phone: 608-664-9500
  • Fax: 608-664-9566
Mailing address:
  • Phone: 608-664-9500
  • Fax: 608-664-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3613-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: