Provider Demographics
NPI:1053321497
Name:PETERSON, KENNETH L (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-1101
Mailing Address - Country:US
Mailing Address - Phone:541-575-0363
Mailing Address - Fax:
Practice Address - Street 1:165 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845-1101
Practice Address - Country:US
Practice Address - Phone:541-575-0363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR39861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice