Basic Information
| Provider Information | |||||||||
| NPI: | 1952542870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960010811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302414134 | ||||||||
| FaxNumber: | 5302242742 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 EUREKA WAY | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960010200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302414134 | ||||||||
| FaxNumber: | 5302411163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 58013 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.