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General NPI Number Information
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NPI Number | 1750722930
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Entity Type | Organization
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Legal Business Name | KIRK J PETERSEN DMD PROFESSIONAL CORP.
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Dates
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Enumeration Date | 07/16/2013
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Last Update Date | 07/16/2013
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Provider Practice Location Address
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Address Line | 3232 W FLORIDA AVE
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City | HEMET
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State | CA
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Zip | 92545-3622
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Country | US
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Telephone | 951-652-4464
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Fax | 951-929-7090
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Provider Business Mailing Address
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Address Line | 3232 W FLORIDA AVE
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City | HEMET
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State | CA
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Zip | 92545-3622
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Country | US
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Telephone | 951-652-4464
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Fax | 951-929-7090
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIRK J PETERSEN
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Credential | DMD
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Telephone | 951-652-4464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 35534
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License Number State | CA
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