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DR. SAMUEL GEORGE PETERSEN D.D.S.
NPI 1780848119
Dentist - Oral and Maxillofacial Surgery in Sonora, CA

Active since July 15, 2008Opted out of Medicare · through Feb 5, 2028
940 SYLVA LN STE K1, SONORA, CA 95370(209) 532-5578(209) 532-6216 Get Directions Write a Review

NPPES record last updated: July 15, 2008. Verified against the NPPES registry weekly; last sync: July 26, 2026.

About Dr. Samuel George Petersen D.d.s. NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

DR. SAMUEL GEORGE PETERSEN D.D.S. (NPI 1780848119) is an individual oral and maxillofacial surgery provider in Sonora, California, licensed in California (51511) and active in the NPI registry since July 2008. He has opted out of Medicare through February 5, 2028 and remains eligible to order and refer.

NPPES Registry Identity

NPI1780848119
Entity TypeIndividualMale
Primary Taxonomy1223S0112X
Provider Legal NameDR. SAMUEL GEORGE PETERSENCredential: D.D.S.
Location Address940 SYLVA LN STE K1Sonora, CA 95370-5969
Mailing Address940 Sylva Ln Ste K1Sonora, CA 95370-5969 · (209) 532-5578 · Fax (209) 532-6216
Phone(209) 532-5578
Fax(209) 532-6216
Sole ProprietorYes
Enumeration DateJuly 15, 2008
✔ NPI 1780848119 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyDentist · Oral and Maxillofacial SurgeryDental Providers
Taxonomy Code1223S0112X
License✔ Licensed in CA · 51511
Definition

An oral and maxillofacial surgery dentist specialized in the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.

940 SYLVA LN STE K1, Sonora, CA 95370
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Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of Oklahoma, Blue Cross and Blue Shield of Texas and more.Insurance ›

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

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Opted out of Medicare

Dr. Samuel George Petersen D.d.s. has filed a Medicare opt-out affidavit. Services are provided under private contract between the provider and the patient, and are not billed to or reimbursed by Medicare. The opt-out is on file from February 5, 2016 through February 5, 2028.

Opt-Out Effective DateFebruary 5, 2016
Opt-Out In Effect ThroughFebruary 5, 2028Opt-out affidavits renew automatically every two years unless cancelled
Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency– Power Mobility DevicesAn opted-out provider can still order and refer for Medicare patients in the categories marked above, even though their own services are not covered.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 95370 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient
$90.32 typical visit price
range $58.87 – $176.60
Typical copayment $22.58 (range $14.71 – $44.15)
Most-billed visit code 99203
Established Patient
$73.16 typical visit price
range $19.28 – $144.60
Typical copayment $18.29 (range $4.82 – $36.15)
Most-billed visit code 99213
Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Samuel Petersen's NPI number?

The NPI number for Samuel Petersen is 1780848119. It was assigned to this individual provider in the NPPES registry on July 15, 2008.

Where is Samuel Petersen located?

Samuel Petersen practices at 940 Sylva Ln Ste K1, Sonora, CA 95370. The listed phone number is (209) 532-5578.

What is Samuel Petersen's specialty?

The primary specialty registered for this NPI is Dentist, specializing in Oral and Maxillofacial Surgery, with taxonomy code 1223S0112X.

Is Samuel Petersen enrolled in Medicare?

No. Samuel Petersen has opted out of Medicare through February 5, 2028. Care is provided under private contracts, and Medicare does not pay for services furnished by providers who have opted out. The provider remains eligible to order and refer services for Medicare patients.

What insurance does Samuel Petersen accept?

Health plans from Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of Oklahoma, Blue Cross and Blue Shield of Texas, Florida Combined Life and Humana and 1 other insurer list Samuel Petersen as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.

When was this NPI record last updated?

The NPPES record for Samuel Petersen was last updated on July 15, 2008. NPI Profile syncs with the weekly NPPES data releases published by CMS.