Healthcare Provider Details

I. General information

NPI: 1598967382
Provider Name (Legal Business Name): PETERS ORTHODONTIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 HELMO AVE N STE 200
OAKDALE MN
55128-6037
US

IV. Provider business mailing address

1099 HELMO AVE N STE 200
OAKDALE MN
55128-6037
US

V. Phone/Fax

Practice location:
  • Phone: 651-578-8401
  • Fax: 651-731-6836
Mailing address:
  • Phone: 651-578-8401
  • Fax: 651-731-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD11028
License Number StateMN

VIII. Authorized Official

Name: DR. SALLY NICOLE PETERS
Title or Position: ORTHODONTIST
Credential: D.D.S., M.S.
Phone: 651-578-8401