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General NPI Number Information
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NPI Number | 1407948060
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Entity Type | Individual
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Provider Name | KRISTY LYNN PETERSEN DDS
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Gender | Female
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Dates
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Enumeration Date | 09/29/2006
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Last Update Date | 01/10/2018
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Provider Practice Location Address
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Address Line | 10150 CITY WALK DR APT C
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City | WOODBURY
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State | MN
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Zip | 55129-9270
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Country | US
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Telephone | 651-714-5555
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Fax |
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Provider Business Mailing Address
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Address Line | 10150 CITY WALK DR APT C
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City | WOODBURY
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State | MN
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Zip | 55129-9270
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Country | US
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Telephone | 651-714-5555
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Fax | 651-714-9005
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5884015
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D12087
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License Number State | MN
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