Active NPI
Edwin Roy Peterson, DDS
- Dentist
- Nevada, MO
National Provider Identifier
1922012061
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 12736
- Practice address
- 629 S Main St
Nevada, MO 64772-3555 - Phone
- (417) 667-3134
- NPI assigned
- Jul 27, 2006
- Sex
- Male
- Sole proprietor
- Yes
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 | 12736 | MO | Primary |
Addresses
Primary practice location
629 S Main St
Nevada, MO 64772-3555
Mailing address
629 S Main St
Nevada, MO 64772-3555
Phone (417) 667-3134
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 |
|---|---|---|---|
| 12736 | MO | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153958400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1922012061",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "629 S MAIN ST",
"city": "NEVADA",
"state": "MO",
"postal_code": "647723555",
"telephone_number": "417-667-3134"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "629 S MAIN ST",
"city": "NEVADA",
"state": "MO",
"postal_code": "647723555",
"telephone_number": "417-667-3134"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSON",
"first_name": "EDWIN",
"middle_name": "ROY",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-27",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MO",
"license": "12736",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Nevada, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.