Provider Demographics
NPI:1043657364
Name:PETERSON, JAKE ALLEN (DDS, MD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ALLEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 SW CHANDLER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3239
Mailing Address - Country:US
Mailing Address - Phone:541-617-3993
Mailing Address - Fax:
Practice Address - Street 1:1475 SW CHANDLER AVE STE 101
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3239
Practice Address - Country:US
Practice Address - Phone:541-617-3993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-151711223S0112X
WADE609416671223S0112X
IDD-5107-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty