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General NPI Number Information
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NPI Number | 1326301359
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Entity Type | Organization
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Legal Business Name | KATIE D. PETERSON, DDS, PC
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Dates
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Enumeration Date | 06/25/2012
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Last Update Date | 06/25/2012
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Provider Practice Location Address
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Address Line | 920 N MAIN ST
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City | MOUNTAIN GROVE
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State | MO
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Zip | 65711-1315
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Country | US
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Telephone | 417-926-4910
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Fax | 417-926-4399
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Provider Business Mailing Address
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Address Line | 920 N MAIN ST
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City | MOUNTAIN GROVE
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State | MO
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Zip | 65711-1315
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Country | US
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Telephone | 417-926-4910
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Fax | 417-926-4399
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KATIE DAWN PETERSON
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Credential | DDS
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Telephone | 417-926-4910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2012015429
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License Number State | MO
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