Healthcare Provider Details

I. General information

NPI: 1013465566
Provider Name (Legal Business Name): KRISTINA PETERSEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 SW 2ND ST
BEAVERTON OR
97005-2615
US

IV. Provider business mailing address

PO BOX 568
CORNELIUS OR
97113-0568
US

V. Phone/Fax

Practice location:
  • Phone: 503-259-5045
  • Fax:
Mailing address:
  • Phone: 503-352-8657
  • Fax: 503-352-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7310
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: