Provider Demographics
NPI:1417945544
Name:PETERSON, KRISCHE, VAN HORN, DDS, LLC
Entity Type:Organization
Organization Name:PETERSON, KRISCHE, VAN HORN, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-842-0705
Mailing Address - Street 1:2210 YALE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-2647
Mailing Address - Country:US
Mailing Address - Phone:785-842-0705
Mailing Address - Fax:785-865-2324
Practice Address - Street 1:2210 YALE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-2647
Practice Address - Country:US
Practice Address - Phone:785-842-0705
Practice Address - Fax:785-865-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS420744OtherBLUE CROSS BLUE SHIELD