Active NPI
Ian Petersen, D.M.D.
- Dentist
- Santa Rosa, CA
National Provider Identifier
1225569916
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 101238
- Practice address
- 2448 Guerneville Rd
Suite 200
Santa Rosa, CA 95403-4175 - Phone
- (707) 579-2808
- NPI assigned
- Mar 23, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 101238 | CA | Primary |
Addresses
Primary practice location
2448 Guerneville Rd
Suite 200
Santa Rosa, CA 95403-4175
Mailing address
2577 Greenvale LN
Santa Rosa, CA 95401-4041
Phone (707) 477-6612
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 101238 | CA | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Petersen Dental Care | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dental Clinic/Center
- Santa Rosa, CA
- NPI 1366256125
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1490227200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1490400000000",
"number": "1225569916",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2577 GREENVALE LN",
"city": "SANTA ROSA",
"state": "CA",
"postal_code": "954014041",
"telephone_number": "707-477-6612"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2448 GUERNEVILLE RD",
"address_2": "SUITE 200",
"city": "SANTA ROSA",
"state": "CA",
"postal_code": "954034175",
"telephone_number": "707-579-2808"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "IAN",
"name_prefix": "Dr.",
"credential": "D.M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-03-23",
"last_updated": "2017-03-25",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "101238",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Santa Rosa, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.