Healthcare Provider Details

I. General information

NPI: 1790818094
Provider Name (Legal Business Name): NEIL E PETERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5019 WEST NORTH AVE
MILWAUKEE WI
53208-1121
US

IV. Provider business mailing address

14320 INDIAN RIDGE
BROOKFIELD WI
53005
US

V. Phone/Fax

Practice location:
  • Phone: 414-445-6500
  • Fax: 414-445-6618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5000681
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: