Provider Demographics
NPI:1386939387
Name:RYAN-PETERKIN, KATHRYN ELIZABETH (BS, DDS, MS)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:RYAN-PETERKIN
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Gender:F
Credentials:BS, DDS, MS
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Mailing Address - Street 1:14177 MAHOGANY AVE.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258
Mailing Address - Country:US
Mailing Address - Phone:414-581-4440
Mailing Address - Fax:904-731-9235
Practice Address - Street 1:9250 BAYMEADOWS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1883
Practice Address - Country:US
Practice Address - Phone:904-731-2120
Practice Address - Fax:904-731-9235
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2013-07-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLDN193751223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics