Provider Demographics
NPI:1285638106
Name:PETERSEN, KIRK JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:JOHN
Last Name:PETERSEN
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 1:1301 S PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-3339
Mailing Address - Country:US
Mailing Address - Phone:951-265-2240
Mailing Address - Fax:
Practice Address - Street 1:501 N INDIAN RD
Practice Address - Street 2:
Practice Address - City:SMITH RIVER
Practice Address - State:CA
Practice Address - Zip Code:95567-9509
Practice Address - Country:US
Practice Address - Phone:707-487-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist