Provider Demographics
NPI:1962890608
Name:PETERSON, KATHERINE TRAWICK (DDS)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:TRAWICK
Last Name:PETERSON
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 1:2344 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-2412
Mailing Address - Country:US
Mailing Address - Phone:510-981-4100
Mailing Address - Fax:
Practice Address - Street 1:2344 6TH ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2412
Practice Address - Country:US
Practice Address - Phone:510-981-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0579891223G0001X
CA650261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice