Provider Demographics
NPI:1962569277
Name:PETERMAN, JENNIFER M (DDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 E BIJOU ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8008
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:
Practice Address - Street 1:1901 W 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-2106
Practice Address - Country:US
Practice Address - Phone:316-832-2838
Practice Address - Fax:316-832-9530
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS603871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS60387OtherKS STATE DENTAL LICENSE
KS200420170BMedicaid