Provider Demographics
NPI:1871756924
Name:PETERSON, GILMAN III (DMD MD)
Entity type:Individual
Prefix:
First Name:GILMAN
Middle Name:
Last Name:PETERSON
Suffix:III
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1267
Mailing Address - Country:US
Mailing Address - Phone:859-498-6204
Mailing Address - Fax:
Practice Address - Street 1:1303 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-3100
Practice Address - Country:US
Practice Address - Phone:859-744-0677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7976122300000X, 1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100071380Medicaid
KY7100067490Medicaid
KY0605807Medicare PIN
KY7100067490Medicaid