Provider Demographics
NPI:1699789115
Name:PETERSON, KEVIN L (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BOYLSTON ST
Mailing Address - Street 2:APT. 9018
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-3929
Mailing Address - Country:US
Mailing Address - Phone:617-216-8042
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKLINE PL
Practice Address - Street 2:SUITE 505
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7224
Practice Address - Country:US
Practice Address - Phone:617-735-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA196701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics