Provider Demographics
NPI:1649489352
Name:PETERSON & REDDY, D.D.S., P.A.
Entity type:Organization
Organization Name:PETERSON & REDDY, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-843-3367
Mailing Address - Street 1:11855 HOLLY LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11855 HOLLY LN
Practice Address - Street 2:SUITE 103
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3114
Practice Address - Country:US
Practice Address - Phone:301-843-3367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD128341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty