Provider Demographics
NPI:1619413093
Name:PETERSON, SCOTT T (DMD MS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 S MARIPOSA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-5224
Mailing Address - Country:US
Mailing Address - Phone:480-440-6923
Mailing Address - Fax:
Practice Address - Street 1:5235 W BASELINE RD
Practice Address - Street 2:#187
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-3122
Practice Address - Country:US
Practice Address - Phone:602-605-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0095771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics