Provider Demographics
NPI:1689795874
Name:PETERSON, KEVIN MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MARK
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 HOT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-1630
Mailing Address - Country:US
Mailing Address - Phone:775-883-1092
Mailing Address - Fax:775-883-1096
Practice Address - Street 1:461 HOT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-1630
Practice Address - Country:US
Practice Address - Phone:775-883-1092
Practice Address - Fax:775-883-1096
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist