Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 015796 | MO |
NPI | 1174975429 |
---|---|
Provider Name | Dr. Alan Clark Peterson SR. |
First Address | Atlanta, GA 30315-4400 |
Second Address | Atlanta, GA 30315-4400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2016 |
Last Update Date | 11/07/2016 |