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NPI Code Detail

MEDICARE: DR. CARLY CHRISTOFERSON PETERSEN DMD

MEDICARE: DR. CARLY CHRISTOFERSON PETERSEN DMD
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
11223G0001XGeneral Practice DentistryD11110OR

General Provider Information

NPI Number : 1841844354
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CARLY CHRISTOFERSON PETERSEN DMD
Provider Business Mailing Address
First Line : 3900 DOUGLAS WAY
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97035-3446
Country : US
Telephone Number : 503-636-8446
Fax Number : 503-636-4446
Provider Business Practice Location Address
First Line : 3900 DOUGLAS WAY
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97035-3446
Country : US
Telephone Number : 503-636-8446
Fax Number : 503-636-4446
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/01/2019
Last Update Date : 03/01/2022

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