Kelsey Peterson, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D-4282 Issued in ID

Practice address

1312 South Washington Street
Emmett, ID 83617

Phone

(208) 941-6640

NPI assigned

Mar 15, 2010

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1268611200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1707782400000",
    "number": "1396069712",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1312 S WASHINGTON AVE STE C",
            "city": "EMMETT",
            "state": "ID",
            "postal_code": "836173596",
            "telephone_number": "208-365-6800",
            "fax_number": "208-365-9600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1312 SOUTH WASHINGTON STREET",
            "city": "EMMETT",
            "state": "ID",
            "postal_code": "83617",
            "telephone_number": "208-941-6640"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "KELSEY",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-03-15",
        "last_updated": "2024-02-13",
        "certification_date": "2024-02-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "ID",
            "license": "D-4282-OR",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "ID",
            "license": "D-4282",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Novitas Academy
• Nutrition Counseling Valerie Lawrence
• Cory Ondler, D.O.
• Melissa Mahcalani Paller, LMSC
• Peterson Orthodontics PLLC
• Petrie White Family Medicine of Idaho (Emmett Family Medicine and Direct Primary Care)
• Jennifer Petrie, MD
• Daniel Michael Pewe, DC
• Debra Anne Phillips, FNP-BC
• Kathryn Margaret Phillips, DPT

• General Practice Dentistry in Emmett, ID
• Providers in Emmett, ID by specialty
• General Practice Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.