Healthcare Provider Details

I. General information

NPI: 1619281177
Provider Name (Legal Business Name): DR. RUTH PETERKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 LAKE AVENUE NORTH
BATTLE LAKE MN
56515
US

IV. Provider business mailing address

PO BOX 332
BATTLE LAKE MN
56515-0332
US

V. Phone/Fax

Practice location:
  • Phone: 218-371-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12830
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: