Healthcare Provider Details

I. General information

NPI: 1427997345
Provider Name (Legal Business Name): KAILA D PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6380 SPLIT ROCK AVE
TWENTYNINE PALMS CA
92277-2550
US

IV. Provider business mailing address

4750 ROUND UP RD
TWENTYNINE PALMS CA
92277-6712
US

V. Phone/Fax

Practice location:
  • Phone: 760-365-9305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number26680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: