Organization
JOHN T PETERSON DDS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN T PETERSON DDS (DENTIST)
(815) 932-3613
Entity
Organization
Contact information
Practice address
200 E COURT ST, SUITE 504, KANKAKEE, IL 60901-3843
(815) 932-3613
Mailing address
200 E COURT ST, SUITE 504, KANKAKEE, IL 60901-3843
(815) 932-3613
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
19A14762
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
021076
FIRST COMMONWEALTH
IL
05
—
1003311
—
IL
01
—
606970
UNITED CONCORDIA
IL
Enumeration date
11/16/2011
Last updated
11/16/2011
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