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General NPI Number Information
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NPI Number | 1073608170
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Entity Type | Individual
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Provider Name | MARK A PETERSON D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 7740 BAY ST SUITE # 1
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City | SEBASTIAN
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State | FL
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Zip | 32958-3427
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Country | US
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Telephone | 772-388-3119
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Fax | 722-388-0250
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Provider Business Mailing Address
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Address Line | 4280 BERRY RD
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City | GRANT
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State | FL
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Zip | 32949-5323
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Country | US
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Telephone | 321-722-9474
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN0011508
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License Number State | FL
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