Provider Demographics
NPI:1871948448
Name:JOHN C. PETERSON D.D.S.
Entity type:Organization
Organization Name:JOHN C. PETERSON D.D.S.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:B
Authorized Official - Last Name:PURSUIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-670-2646
Mailing Address - Street 1:8729 LA TIJERA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3906
Mailing Address - Country:US
Mailing Address - Phone:310-670-2646
Mailing Address - Fax:310-670-1618
Practice Address - Street 1:8729 LA TIJERA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3906
Practice Address - Country:US
Practice Address - Phone:310-670-2646
Practice Address - Fax:310-670-1618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRAIG B. PURSUIT D.D.S. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28789122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty