Individual
KELSEY PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
1312 SOUTH WASHINGTON STREET, EMMETT, ID 83617
(208) 941-6640
Mailing address
1312 S WASHINGTON AVE STE C, EMMETT, ID 83617-3596
(208) 365-6800
(208) 365-9600
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D-4282
ID
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
D-4282-OR
ID
Other
Enumeration date
03/15/2010
Last updated
02/13/2024
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