Individual
JAMES PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2501 W ILES AVE STE A, SPRINGFIELD, IL 62704-6482
(217) 452-3057
Mailing address
2501 W ILES AVE STE A, SPRINGFIELD, IL 62704-6482
(217) 452-3057
Taxonomy
Speciality
Code
Description
License number
State
1223D0001X
Public Health Dentistry
019029045
IL
1223G0001X
General Practice Dentistry
Primary
019029045
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
019029045
ILLINOIS LICENSE NUMBER
IL
Enumeration date
06/15/2012
Last updated
03/04/2025
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