Provider Demographics
NPI:1912267618
Name:PEDERSEN, KATHERINE D (RDH, PHRDH)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:D
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:RDH, PHRDH
Other - Prefix:
Other - First Name:KATHERINE (KATY)
Other - Middle Name:DONELLE
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 648
Mailing Address - Street 2:111 NORTH DEWEY
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-0648
Mailing Address - Country:US
Mailing Address - Phone:308-696-1201
Mailing Address - Fax:
Practice Address - Street 1:111 NORTH DEWEY
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-0648
Practice Address - Country:US
Practice Address - Phone:308-696-1201
Practice Address - Fax:308-696-1204
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2153124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist