Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H7310 | OR |
NPI | 1013465566 |
---|---|
Provider Name | Kristina Petersen |
First Address | Cornelius, OR 97113-0568 |
Second Address | Beaverton, OR 97005-2615 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2016 |
Last Update Date | 13/09/2016 |