=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962746545
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETERSON FAMILY DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2012
-----------------------------------------------------
Last Update Date | 12/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 LOCUST ST
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03820-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-742-6546
-----------------------------------------------------
Fax | 603-742-7043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 LOCUST ST
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03820-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-742-6546
-----------------------------------------------------
Fax | 603-742-7043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | STEPHAN L PETERSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 603-742-6546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1725
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------