=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093533762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETERSON DENTAL GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 08/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7920 N DECATUR BLVD SUITE 106
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-673-5772
-----------------------------------------------------
Fax | 702-921-9931
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 872710
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98687-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-869-7645
-----------------------------------------------------
Fax | 877-725-7443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PC OWNER
-----------------------------------------------------
Name | DR. BRADLEY R PETERSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 360-869-7645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------