Healthcare Provider Details

I. General information

NPI: 1003546128
Provider Name (Legal Business Name): JESSICA PETERSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25477 MAIN ST # PO454
NISSWA MN
56468-5001
US

IV. Provider business mailing address

25477 MAIN ST # PO454
NISSWA MN
56468-5001
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-6330
  • Fax:
Mailing address:
  • Phone: 218-963-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14758
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: