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General NPI Number Information
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NPI Number | 1003170531
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Entity Type | Individual
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Provider Name | BETHANY ANNE PETERSEN DDS
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Gender | Female
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Dates
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Enumeration Date | 06/29/2012
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Last Update Date | 06/29/2012
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Provider Practice Location Address
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Address Line | 4410 E RIVERSIDE DR STE 150
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City | AUSTIN
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State | TX
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Zip | 78741-4759
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Country | US
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Telephone | 855-512-7625
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Fax |
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Provider Business Mailing Address
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Address Line | 1620 E RIVERSIDE DR APT 4034
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City | AUSTIN
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State | TX
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Zip | 78741-1026
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Country | US
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Telephone | 713-492-7719
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 28004
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License Number State | TX
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