Provider Demographics
NPI:1407499957
Name:PETERSON, KEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:PETERSON
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 1:11901 ABESS BLVD APT 4123
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6041
Mailing Address - Country:US
Mailing Address - Phone:906-281-1915
Mailing Address - Fax:
Practice Address - Street 1:1607 WESTGATE CIR STE 400
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8080
Practice Address - Country:US
Practice Address - Phone:615-829-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL239821223X0400X
TN111691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics