Provider Demographics
NPI:1538207097
Name:PETERS-NELSON, STACEY ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANN
Last Name:PETERS-NELSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9121 FOLSOM BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2473
Mailing Address - Country:US
Mailing Address - Phone:916-362-1137
Mailing Address - Fax:
Practice Address - Street 1:9121 FOLSOM BLVD STE E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2473
Practice Address - Country:US
Practice Address - Phone:916-362-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice