Provider Demographics
NPI:1285852426
Name:PETERSEN, R. KELLY (DDS)
Entity Type:Individual
Prefix:
First Name:R.
Middle Name:KELLY
Last Name:PETERSEN
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 1:17021 LINCOLN AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-3146
Mailing Address - Country:US
Mailing Address - Phone:720-851-7069
Mailing Address - Fax:
Practice Address - Street 1:17021 LINCOLN AVE UNIT B
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-3146
Practice Address - Country:US
Practice Address - Phone:720-851-7069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice