Provider Demographics
NPI:1275150377
Name:PETERKIN, CHANTOL (DDS)
Entity Type:Individual
Prefix:
First Name:CHANTOL
Middle Name:
Last Name:PETERKIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CENTER DR # D1-13C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3006
Mailing Address - Country:US
Mailing Address - Phone:352-273-5651
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR # D1-30
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3006
Practice Address - Country:US
Practice Address - Phone:352-273-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist