Healthcare Provider Details

I. General information

NPI: 1396069712
Provider Name (Legal Business Name): KELSEY PETERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 SOUTH WASHINGTON STREET
EMMETT ID
83617
US

IV. Provider business mailing address

1312 S WASHINGTON AVE STE C
EMMETT ID
83617-3596
US

V. Phone/Fax

Practice location:
  • Phone: 208-941-6640
  • Fax:
Mailing address:
  • Phone: 208-365-6800
  • Fax: 208-365-9600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4282
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-4282-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: