MEDICARE: ERIC L PETERSON DDS PC

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	049002	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639165384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERIC L PETERSON DDS PC

Provider Business Mailing Address
First Line	:	225 SCOTTWOOD AVE
Second Line	:
City	:	ELMIRA HEIGHTS
State	:	NY
Zip	:	14903-1322
Country	:	US
Telephone Number	:	607-733-3616
Fax Number	:	607-733-1053

Provider Business Practice Location Address
First Line	:	225 SCOTTWOOD AVE
Second Line	:
City	:	ELMIRA HEIGHTS
State	:	NY
Zip	:	14903-1322
Country	:	US
Telephone Number	:	607-733-3616
Fax Number	:	607-733-1053

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ERIC LAURENCE PETERSON
Credential	:	DDS
Telephone Number	:	607-733-3616

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	08/22/2020

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