Active NPI
Kelissa L Peterson, DMD
- General Practice Dentistry
- Streator, IL
National Provider Identifier
1861047284
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 019032290
- Practice address
- 318 N Bloomington St
Streator, IL 61364-2218 - Phone
- (815) 672-2647
- Fax
- (815) 672-5201
- NPI assigned
- Aug 2, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 019032290 | IL | Primary |
Addresses
Primary practice location
318 N Bloomington St
Streator, IL 61364-2218
Mailing address
2632 N 3739TH Rd
Sheridan, IL 60551-9474
Phone (815) 207-9735
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019032290 | IL | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1564704000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1564704000000",
"number": "1861047284",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2632 N 3739TH RD",
"city": "SHERIDAN",
"state": "IL",
"postal_code": "605519474",
"telephone_number": "815-207-9735"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "318 N BLOOMINGTON ST",
"city": "STREATOR",
"state": "IL",
"postal_code": "613642218",
"telephone_number": "815-672-2647",
"fax_number": "815-672-5201"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSON",
"first_name": "KELISSA",
"middle_name": "L",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-08-02",
"last_updated": "2019-08-02",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "IL",
"license": "019032290",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Streator, IL
- Parker Nursing & Rehabilitation Center, LLC
- Parkview Family Practice, P.C.
- James Edward Parr, RPH
- Susan C. Pavlick, RN-C, FNP
- Peak Orthopaedic & Sports Caresc
- Phillips Investments, LLC - Streator Operations Series
- Kristy Ann Pierce-Schultz, LCSW
- Michelle Pitstick, OT
- Robert Patrick Pode, D.O.
- Podzamsky Medical Services
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.