Provider Demographics
NPI:1275849986
Name:PETTERSEN, KYLE (DDS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PETTERSEN
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 1:207 13TH ST NE APT 2306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4611
Mailing Address - Country:US
Mailing Address - Phone:561-715-3397
Mailing Address - Fax:
Practice Address - Street 1:609 BEAVER RUIN RD NW # A
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:678-606-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00259831223G0001X
CA595471223G0001X
GADN0161371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice