Provider Demographics
NPI:1902975360
Name:PETERSON, KIRSTIN LEIGH (RDH)
Entity Type:Individual
Prefix:MS
First Name:KIRSTIN
Middle Name:LEIGH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:KIRSTIN
Other - Middle Name:LEIGH
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH BS
Mailing Address - Street 1:09 5020 NOVITSKI HALL 1 UNM 2320 TUCKER NE
Mailing Address - Street 2:UNIVERSITY OF NEW MEXICO DEPT. OF DENTAL MSC
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4513
Mailing Address - Fax:505-272-5584
Practice Address - Street 1:UNIVERSITY OF NEW MEXICO DEPT OF DENTAL MSC
Practice Address - Street 2:09 5020 NOVITSKI HALL 1 UNM 2320 TUCKER NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-4513
Practice Address - Fax:505-272-5584
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH574124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist