Healthcare Provider Details

I. General information

NPI: 1386939387
Provider Name (Legal Business Name): KATHRYN ELIZABETH RYAN-PETERKIN B.S., D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 BAYMEADOWS RD SUITE 300
JACKSONVILLE FL
32256-1883
US

IV. Provider business mailing address

14177 MAHOGANY AVE.
JACKSONVILLE FL
32258
US

V. Phone/Fax

Practice location:
  • Phone: 904-731-2120
  • Fax: 904-731-9235
Mailing address:
  • Phone: 414-581-4440
  • Fax: 904-731-9235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN19375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: