Provider Demographics
NPI:1689241697
Name:PETERSON, COLLIN (DMD)
Entity type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 SECURITY SQ
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1952
Mailing Address - Country:US
Mailing Address - Phone:228-896-6321
Mailing Address - Fax:
Practice Address - Street 1:412 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1952
Practice Address - Country:US
Practice Address - Phone:228-896-6321
Practice Address - Fax:228-896-6322
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4197-21122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist