Provider Demographics
NPI:1952542870
Name:PETERSEN, MELISSA (DDS)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0811
Mailing Address - Country:US
Mailing Address - Phone:530-241-4134
Mailing Address - Fax:530-224-2742
Practice Address - Street 1:2950 EUREKA WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0200
Practice Address - Country:US
Practice Address - Phone:530-241-4134
Practice Address - Fax:530-241-1163
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA580131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice