Provider Demographics
NPI:1598314023
Name:KORN, PETER (RDHAP)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KORN
Suffix:
Gender:M
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11135 ROSEMARY DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-5945
Mailing Address - Country:US
Mailing Address - Phone:530-906-7609
Mailing Address - Fax:
Practice Address - Street 1:11135 ROSEMARY DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5945
Practice Address - Country:US
Practice Address - Phone:530-906-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA757125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist