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NPI Code Detail

MEDICARE: DR. KIRK JOHN PETERSEN D.M.D.

MEDICARE: DR. KIRK JOHN PETERSEN D.M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentist35534CA

General Provider Information

NPI Number : 1285638106
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KIRK JOHN PETERSEN D.M.D.
Provider Business Mailing Address
First Line : 1301 S PEBBLE BEACH DR
Second Line :
City : CRESCENT CITY
State : CA
Zip : 95531-3339
Country : US
Telephone Number : 951-265-2240
Fax Number :
Provider Business Practice Location Address
First Line : 501 N INDIAN RD
Second Line :
City : SMITH RIVER
State : CA
Zip : 95567-9509
Country : US
Telephone Number : 707-487-0215
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2005
Last Update Date : 03/03/2018

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