David Peterson, DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

021001236 Issued in IL

Practice address

1619 Brandywine LN
Dixon, IL 61021-8757

Phone

(815) 622-4740

NPI assigned

Sep 12, 2018

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1536710400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1536710400000",
    "number": "1215410584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1619 BRANDYWINE LN",
            "city": "DIXON",
            "state": "IL",
            "postal_code": "610218757",
            "telephone_number": "815-622-4740"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1619 BRANDYWINE LN",
            "city": "DIXON",
            "state": "IL",
            "postal_code": "610218757",
            "telephone_number": "815-622-4740"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "DAVID",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-09-12",
        "last_updated": "2018-09-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "IL",
            "license": "021001236",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "019017734",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Stacey Penaflor
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• Michelle Kay Petersen
• Tiffany Petersen, RBT
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• Laura C. Petrie, D.C.
• Patricia Petrie, D.C.
• Alexis Pfeiffer, QMHP
• Valarie Pfoutz, APN

• Oral and Maxillofacial Surgery (Dentist) in Dixon, IL
• Providers in Dixon, IL by specialty
• Oral and Maxillofacial Surgery (Dentist) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.