| Name: | Peterson Dental, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 25 Mar 2010 (15 years ago) |
| Entity Number: | 000-445-304 |
| Register Number: | 000445304 |
| County: | Tuscaloosa |
| Place of Formation: | Tuscaloosa County |
| Principal Address: | TUSCALOOSA, AL |
| Registered Office Street Address: | 2618 8TH STTUSCALOOSA, AL 35401 |
| Registered Office Street Address ZIP Code: | 35401 |
Activities
ANY LAWFUL ACTIVITY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1811366198 | 2015-09-17 | 2015-09-17 | 1101 HIGROVE PKWY, SUITE 105, LEEDS, AL, 350941703, US | 1101 HIGROVE PKWY, SUITE 105, LEEDS, AL, 350941703, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 205-699-1155 |
| Fax | 2056991159 |
Authorized person
| Name | NICOLE PETERSON |
| Role | CFO |
| Phone | 2056991155 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| License Number | 5696 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS PROVIDER # |
| Number | 511-11930 |
| State | AL |
| Issuer | CIGNA GEHA PROVIDER # |
| Number | 1102337492 |
| Issuer | UNITED CONCORDIA PROVIDER # |
| Number | 2586372 |
| State | AL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PETERSON DENTAL 401K PLAN | 2023 | 272124635 | 2024-09-25 | PETERSON DENTAL | 11 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2024-09-25 |
| Name of individual signing | MICHAEL VANDERFORD |
| Valid signature | Filed with authorized/valid electronic signature |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 2056991155 |
| Plan sponsor’s address | 1101 HIGROVE PARKWAY, SUITE 105, LEEDS, AL, 35094 |
Signature of
| Role | Plan administrator |
| Date | 2023-09-22 |
| Name of individual signing | MICHAEL VANDERFORD |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 2056991155 |
| Plan sponsor’s address | 1101 HIGROVE PARKWAY, SUITE 105, LEEDS, AL, 35094 |
Signature of
| Role | Plan administrator |
| Date | 2022-08-23 |
| Name of individual signing | ERIC PETERSON |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 2056991155 |
| Plan sponsor’s address | 1101 HIGROVE PARKWAY, SUITE 105, LEEDS, AL, 35094 |
Signature of
| Role | Plan administrator |
| Date | 2021-09-17 |
| Name of individual signing | ERIC PETERSON |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 2056991155 |
| Plan sponsor’s address | 1101 HIGROVE PARKWAY, SUITE 105, LEEDS, AL, 35094 |
Signature of
| Role | Plan administrator |
| Date | 2020-09-16 |
| Name of individual signing | ERIC PETERSON |
| Name | Role | Address |
|---|---|---|
| RICHARDSON, STEVE | Agent | 2618 8TH STREETTUSCALOOSA, AL 35401 |
| Name | Role | Address |
|---|---|---|
| PETERSON, ERIC | Member | 1507 PARNELL DRLEEDS, AL 35094 |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
