Provider Demographics
NPI:1477006047
Name:PETERSEN, CHRISTIAN D (DDS, MS)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:D
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BEEMAN PL
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7009
Mailing Address - Country:US
Mailing Address - Phone:785-239-4181
Mailing Address - Fax:
Practice Address - Street 1:228 BEEMAN PL
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7009
Practice Address - Country:US
Practice Address - Phone:785-239-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE73121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice