Provider Demographics
NPI:1326301359
Name:KATIE D. PETERSON, DDS, PC
Entity Type:Organization
Organization Name:KATIE D. PETERSON, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-926-4910
Mailing Address - Street 1:920 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1315
Mailing Address - Country:US
Mailing Address - Phone:417-926-4910
Mailing Address - Fax:417-926-4399
Practice Address - Street 1:920 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1315
Practice Address - Country:US
Practice Address - Phone:417-926-4910
Practice Address - Fax:417-926-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120154291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty