Derek Gene Petersen, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

9978 Issued in CO

Practice address

3303 W 144TH Ave Unit 100
Broomfield, CO 80023-9464

Phone

(720) 308-9798

NPI assigned

Aug 25, 2009

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

Medicare fee-for-service enrollment

Enrolled in CO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1251158400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1391558400000",
    "number": "1487887451",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3303 W 144TH AVE UNIT 100",
            "city": "BROOMFIELD",
            "state": "CO",
            "postal_code": "800239464",
            "telephone_number": "720-308-9798"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3303 W 144TH AVE UNIT 100",
            "city": "BROOMFIELD",
            "state": "CO",
            "postal_code": "800239464",
            "telephone_number": "720-308-9798"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "DEREK",
        "middle_name": "GENE",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2009-08-25",
        "last_updated": "2014-02-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CO",
            "license": "9978",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Marisa Perez-Wilson, O.D.
• Perfect Teeth - West 120TH Avenue P.C.
• Stephanie Lynn Perri, LPC
• Susan K. Peters, MS, LPC
• Debra Jean Petersen, NP
• Catherine Elizabeth Peterson, PA
• Eric Peterson, PHARMD
• Jenna Peterson, MA, LPCC
• Rebecca Renee Peterson, CBE, CPD, CNA
• Adam Harrison Petrovich

• General Practice Dentistry in Broomfield, CO
• Providers in Broomfield, CO by specialty
• General Practice Dentistry in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 5, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.