Organization
PETERSON DENTAL, LLC
Active
Other names
Peterson Dental
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE PETERSON (CFO)
(205) 699-1155
Entity
Organization
Contact information
Practice address
1101 HIGROVE PKWY, SUITE 105, LEEDS, AL 35094-1703
(205) 699-1155
(205) 699-1159
Mailing address
1101 HIGROVE PKWY, SUITE 105, LEEDS, AL 35094-1703
(205) 699-1155
(205) 699-1159
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
5696
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1102337492
CIGNA GEHA PROVIDER #
—
01
—
2586372
UNITED CONCORDIA PROVIDER #
AL
01
—
511-11930
BCBS PROVIDER #
AL
Enumeration date
09/17/2015
Last updated
09/17/2015
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