Basic Information
| Provider Information | |||||||||
| NPI: | 1902975360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KIRSTIN | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | KIRSTIN | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.D.H. B.S. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 09 5020 NOVITSKI HALL 1 UNM 2320 TUCKER NE | ||||||||
| Address2: | UNIVERSITY OF NEW MEXICO DEPT. OF DENTAL MSC | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724513 | ||||||||
| FaxNumber: | 5052725584 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIVERSITY OF NEW MEXICO DEPT OF DENTAL MSC | ||||||||
| Address2: | 09 5020 NOVITSKI HALL 1 UNM 2320 TUCKER NE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724513 | ||||||||
| FaxNumber: | 5052725584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH574 | NM | Y | Dental Providers | Dental Hygienist |
No ID Information.