Provider Demographics
NPI:1487766853
Name:PETERSON, BRIAN R (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:PETERSON
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 1:6812 E BROWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-3757
Mailing Address - Country:US
Mailing Address - Phone:480-325-3368
Mailing Address - Fax:480-325-0718
Practice Address - Street 1:6812 E BROWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3757
Practice Address - Country:US
Practice Address - Phone:480-325-3368
Practice Address - Fax:480-325-0718
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD 50141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ477754OtherACCESS ID