Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 6930 | NV |
NPI | 1003346917 |
---|---|
Provider Name | Dr. Brady Todd Petersen |
First Address | Las Vegas, NV 89146 |
Second Address | Las Vegas, NV 89146-5181 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2017 |
Last Update Date | 03/11/2017 |