Carly Christoferson Petersen, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D11110 Issued in OR

Practice address

3900 Douglas Way
Lake Oswego, OR 97035-3446

Phone

(503) 636-8446

Fax

(503) 636-4446

NPI assigned

Aug 1, 2019

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Carly K Christoferson DMD PC

  • Dental Clinic/Center
  • Lake Oswego, OR
  • NPI 1548917321
  NPD Authorized official
• Wikle Dentistry LLC

  • General Practice Dentistry
  • Lake Oswego, OR
  • NPI 1174997142
  NPD (past)

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

{
    "created_epoch": "1564617600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1646092800000",
    "number": "1841844354",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3900 DOUGLAS WAY",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970353446",
            "telephone_number": "503-636-8446",
            "fax_number": "503-636-4446"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3900 DOUGLAS WAY",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970353446",
            "telephone_number": "503-636-8446",
            "fax_number": "503-636-4446"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "CARLY",
        "middle_name": "CHRISTOFERSON",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2019-08-01",
        "last_updated": "2022-03-01",
        "certification_date": "2022-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OR",
            "license": "D11110",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "info@beadnellfamilydentistry.com",
            "affiliation": "N",
            "endpointDescription": "Info Address",
            "address_1": "1616 SW Sunset Blvd Ste A",
            "city": "Portland",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972392641",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Arianna Perez
• Sarah Perine
• Anne Elizabeth Pernichele, DC
• Lisa Lynn Perreault, PT
• Dylann Perrone
• Peterson Orthodontics & Periodontics, LLC
• Larry Len Peterson, M.D.
• Noel S. Peterson, N.D.
• Charles Justin Petit, M.D.
• Mark A. Petroff, M.D.

• General Practice Dentistry in Lake Oswego, OR
• Providers in Lake Oswego, OR by specialty
• General Practice Dentistry in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2022; 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.