Provider Demographics
NPI:1750722930
Name:KIRK J PETERSEN DMD PROFESSIONAL CORP.
Entity type:Organization
Organization Name:KIRK J PETERSEN DMD PROFESSIONAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:951-652-4464
Mailing Address - Street 1:3232 W FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-3622
Mailing Address - Country:US
Mailing Address - Phone:951-652-4464
Mailing Address - Fax:951-929-7090
Practice Address - Street 1:3232 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3622
Practice Address - Country:US
Practice Address - Phone:951-652-4464
Practice Address - Fax:951-929-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35534332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment