MEDICARE: MRS. KRISTY PETERS RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	0402004698	VA

General Provider Information

NPI Number	:	1457058356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTY PETERS RDH

Provider Business Mailing Address
First Line	:	208 DEER TRAK
Second Line	:
City	:	CLOVERDALE
State	:	VA
Zip	:	24077-3059
Country	:	US
Telephone Number	:	540-892-6336
Fax Number	:

Provider Business Practice Location Address
First Line	:	6027 PETERS CREEK RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24019-4029
Country	:	US
Telephone Number	:	540-366-5373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2023
Last Update Date	:	02/10/2023

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