Samuel George Petersen, D.D.S.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

51511 Issued in CA

Practice address

940 Sylva LN Ste K1
Sonora, CA 95370-5969

Phone

(209) 532-5578

Fax

(209) 532-6216

NPI assigned

Jul 15, 2008

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

Not listed in the public Medicare enrollment file

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.

Opted out of Medicare

Yes, effective Feb 5, 2016 through Feb 5, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Sonora Oral & Maxillofacial Surgery Dental Group

  dba Sonora Oral & Maxillofacial Surgery

  • Oral and Maxillofacial Surgery (Dentist)
  • Sonora, CA
  • NPI 1972896785
  NPD (past)

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

{
    "created_epoch": "1216080000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1216080000000",
    "number": "1780848119",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "940 SYLVA LN STE K1",
            "city": "SONORA",
            "state": "CA",
            "postal_code": "953705969",
            "telephone_number": "209-532-5578",
            "fax_number": "209-532-6216"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "940 SYLVA LN STE K1",
            "city": "SONORA",
            "state": "CA",
            "postal_code": "953705969",
            "telephone_number": "209-532-5578",
            "fax_number": "209-532-6216"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "SAMUEL",
        "middle_name": "GEORGE",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-07-15",
        "last_updated": "2008-07-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "CA",
            "license": "51511",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Harlan Roger Perry Jr., HEARING AID DISPENSE
• Matthew Lincoln Personius, M.D.
• Peter a. Beoris, MD, Inc.
• Alan E. Peters, M.D.
• Christi L Petersen, FNP
• Cheryl Lynn Peterson, M.S.
• Jill Peterson, OTR/L
• Steven H Peterson, MD
• Daniel B Phillips, M.D.
• Janene R Phillips, RN, FNP

• Oral and Maxillofacial Surgery (Dentist) in Sonora, CA
• Providers in Sonora, CA by specialty
• Oral and Maxillofacial Surgery (Dentist) in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2008; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.