Provider Demographics
NPI:1285947259
Name:PETERSON, KYLE W (DDS)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-1450
Mailing Address - Country:US
Mailing Address - Phone:309-797-2001
Mailing Address - Fax:
Practice Address - Street 1:609 22ND ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-1450
Practice Address - Country:US
Practice Address - Phone:309-797-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08753122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist