Provider Demographics
NPI:1407948060
Name:PETERSEN, KRISTY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:LYNN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10150 CITY WALK DR APT C
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-9270
Mailing Address - Country:US
Mailing Address - Phone:651-714-5555
Mailing Address - Fax:651-714-9005
Practice Address - Street 1:10150 CITY WALK DR APT C
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-9270
Practice Address - Country:US
Practice Address - Phone:651-714-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5884015122300000X
MND12087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist