Provider Demographics
NPI:1457058356
Name:PETERS, KRISTY (RDH)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 DEER TRAK
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24077-3059
Mailing Address - Country:US
Mailing Address - Phone:540-892-6336
Mailing Address - Fax:
Practice Address - Street 1:6027 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4029
Practice Address - Country:US
Practice Address - Phone:540-366-5373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402004698124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist