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General NPI Number Information
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NPI Number | 1083821334
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Entity Type | Organization
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Legal Business Name | PETERSON DENTAL GROUP, PC
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/22/2025
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Provider Practice Location Address
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Address Line | 4451 N RANCHO DR
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City | LAS VEGAS
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State | NV
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Zip | 89130-3405
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Country | US
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Telephone | 702-313-6868
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Fax | 702-313-6873
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Provider Business Mailing Address
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Address Line | PO BOX 872710
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City | VANCOUVER
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State | WA
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Zip | 98687-2710
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Country | US
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Telephone | 360-869-7645
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Fax | 877-725-7443
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Authorized Official
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Title or Position | PC OWNER/PRESIDENT
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Name | DR. BRADLEY R PETERSON
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Credential | DDS
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Telephone | 360-869-7645
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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 |
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License Number State |
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