Provider Demographics
NPI:1679778138
Name:DR NEIL E PETERSON & ASSOC
Entity type:Organization
Organization Name:DR NEIL E PETERSON & ASSOC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-445-6600
Mailing Address - Street 1:5019 W NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1121
Mailing Address - Country:US
Mailing Address - Phone:414-445-6600
Mailing Address - Fax:414-445-6618
Practice Address - Street 1:5019 W NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1121
Practice Address - Country:US
Practice Address - Phone:414-445-6600
Practice Address - Fax:414-445-6618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38375200Medicaid