Provider Demographics
NPI:1023245099
Name:PEDERSEN, DANIEL L (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4980 BARRANCA PKWY STE 206
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-8655
Mailing Address - Country:US
Mailing Address - Phone:949-379-3245
Mailing Address - Fax:949-379-3248
Practice Address - Street 1:4980 BARRANCA PKWY STE 206
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8655
Practice Address - Country:US
Practice Address - Phone:949-379-3245
Practice Address - Fax:949-379-3248
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice