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General NPI Number Information
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NPI Number | 1316430952
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Entity Type | Organization
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Legal Business Name | PETERSON DENTAL CARE LLC
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Dates
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Enumeration Date | 06/08/2018
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Last Update Date | 04/16/2025
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Provider Practice Location Address
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Address Line | 2501 W ILES AVE STE A
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City | SPRINGFIELD
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State | IL
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Zip | 62704-6482
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Country | US
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Telephone | 217-787-4015
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Fax |
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Provider Business Mailing Address
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Address Line | 1700 MOUND RD
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City | JACKSONVILLE
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State | IL
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Zip | 62650-2260
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Country | US
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Telephone | 630-780-9964
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAMES PETERSON
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Credential | DDS
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Telephone | 630-780-9964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019029045
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License Number State | IL
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