=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912452558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTT T PETERSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2016
-----------------------------------------------------
Last Update Date | 08/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4216 S MARIPOSA DR
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-710-2226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25240 LAWTON AVE
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-3541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-710-2226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. SCOTT T PETERSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 801-710-2226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D009577
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------