Provider Demographics
NPI:1609285774
Name:PETERSCHMIDT, KATHRYN ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:PETERSCHMIDT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 W WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383
Mailing Address - Country:US
Mailing Address - Phone:503-769-2788
Mailing Address - Fax:503-769-2728
Practice Address - Street 1:6395 KEIZER STATION BLVD NE
Practice Address - Street 2:#101
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-2305
Practice Address - Country:US
Practice Address - Phone:971-267-2033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-03
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice