Provider Demographics
NPI:1073509139
Name:PETERSON, ERIK J (DDS)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:LINDSBORG
Mailing Address - State:KS
Mailing Address - Zip Code:67456-0311
Mailing Address - Country:US
Mailing Address - Phone:785-227-2299
Mailing Address - Fax:785-227-2620
Practice Address - Street 1:101 N. HARRISON
Practice Address - Street 2:
Practice Address - City:LINDSBORG
Practice Address - State:KS
Practice Address - Zip Code:67456-2417
Practice Address - Country:US
Practice Address - Phone:785-227-2299
Practice Address - Fax:785-227-2620
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS6795122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017300OtherBLUE CROSS BLUE SHIELD
KS1002250008Medicaid