Individual
DOUGLAS E PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
263 FARMINGTON AVE, FARMINGTON, CT 06030-0001
(860) 679-2952
(860) 679-4760
Mailing address
263 FARMINGTON AVE, PROVIDER ENROLLMENT, FARMINGTON, CT 06030-2212
(860) 679-7503
(860) 679-1610
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
007480
CT
1223G0001X
General Practice Dentistry
007480
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1003813445
—
CT
Enumeration date
06/30/2005
Last updated
05/12/2021
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