Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 28004 | TX |
NPI | 1003170531 |
---|---|
Provider Name | Bethany Anne Petersen |
First Address | Austin, TX 78741-1026 |
Second Address | Austin, TX 78741-4759 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2012 |
Last Update Date | 29/06/2012 |