Provider Demographics
NPI:1003486093
Name:PEDERSEN, KAI (DMD)
Entity type:Individual
Prefix:DR
First Name:KAI
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 WINROW RD
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-5080
Mailing Address - Country:US
Mailing Address - Phone:520-533-9200
Mailing Address - Fax:520-533-5246
Practice Address - Street 1:2240 WINROW RD
Practice Address - Street 2:
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613-5080
Practice Address - Country:US
Practice Address - Phone:520-533-9200
Practice Address - Fax:520-533-5246
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD012042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODEN.00204746OtherSTATE LICENSE