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General NPI Number Information
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NPI Number | 1457875700
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Entity Type | Organization
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Legal Business Name | PETERSON ORTHODONTICS & PERIODONTICS, LLC
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Dates
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Enumeration Date | 07/28/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 15962 BOONES FERRY RD STE 108
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-4359
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Country | US
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Telephone | 503-699-6569
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Fax |
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Provider Business Mailing Address
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Address Line | 4420 SE 51ST AVE
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City | PORTLAND
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State | OR
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Zip | 97206-3910
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST, MEMBER OF LLC
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Name | DR. VANESSA N B PETERSON
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Credential | DDS, MS
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Telephone | 909-518-7743
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State | OR
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