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General NPI Number Information
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NPI Number | 1295647972
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Entity Type | Organization
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Legal Business Name | NATHANIEL J PETERSON DMD PLLC
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Dates
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Enumeration Date | 09/18/2026
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Last Update Date | 09/18/2026
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Provider Practice Location Address
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Address Line | 1403 TROY RD STE B
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-2590
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Country | US
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Telephone | 630-618-9211
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Fax |
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Provider Business Mailing Address
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Address Line | 837 MADISON AVE
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-2323
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Country | US
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Telephone | 630-618-9211
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. NATHANIEL J PETERSON
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Credential | DMD
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Telephone | 630-618-9211
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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 |
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License Number State |
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