MEDICARE: DR. BRUCE A PETERSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	A-13716	IL

General Provider Information

NPI Number	:	1518022912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE A PETERSON D.D.S.

Provider Business Mailing Address
First Line	:	2917 17TH ST
Second Line	:
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-5382
Country	:	US
Telephone Number	:	309-788-6001
Fax Number	:	309-788-6450

Provider Business Practice Location Address
First Line	:	2917 17TH ST
Second Line	:
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-5382
Country	:	US
Telephone Number	:	309-788-6001
Fax Number	:	309-788-6450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/08/2007

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