Provider Demographics
NPI:1487887451
Name:PETERSEN, DEREK GENE (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:GENE
Last Name:PETERSEN
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 1:3303 W 144TH AVE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-9464
Mailing Address - Country:US
Mailing Address - Phone:720-308-9798
Mailing Address - Fax:
Practice Address - Street 1:3303 W 144TH AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-9464
Practice Address - Country:US
Practice Address - Phone:720-308-9798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice