MEDICARE: DR. KRISTY LYNN PETERSEN DDS

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
1	122300000X	Dentist	5884015	WI
2	122300000X	Dentist	D12087	MN

General Provider Information

NPI Number	:	1407948060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTY LYNN PETERSEN DDS

Provider Business Mailing Address
First Line	:	10150 CITY WALK DR APT C
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55129-9270
Country	:	US
Telephone Number	:	651-714-5555
Fax Number	:	651-714-9005

Provider Business Practice Location Address
First Line	:	10150 CITY WALK DR APT C
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55129-9270
Country	:	US
Telephone Number	:	651-714-5555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	01/10/2018

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