Basic Information
| Provider Information | |||||||||
| NPI: | 1962569277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERMAN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 W 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672032106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168322838 | ||||||||
| FaxNumber: | 3168329530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 60387 | KS | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 60387 | 01 | KS | KS STATE DENTAL LICENSE | OTHER | 200420170B | 05 | KS | MEDICAID |