Basic Information
| Provider Information | |||||||||
| NPI: | 1093444804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | STACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11605 DESTINATION DR APT 5404 | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800214793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014269415 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1927 COLORADO STATE HWY 7 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ERIE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208749039 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00205330 | CO | Y | Dental Providers | Dentist |
No ID Information.