Healthcare Provider Details

I. General information

NPI: 1396856100
Provider Name (Legal Business Name): PETERSON DENTAL ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 W ST GERMAIN ST #101
ST CLOUD MN
56301-3511
US

IV. Provider business mailing address

816 W ST GERMAIN ST #101
ST CLOUD MN
56301-3511
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-2454
  • Fax: 320-252-2232
Mailing address:
  • Phone: 320-252-2454
  • Fax: 320-252-2232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. RUSSELL THOMAS PETERSON
Title or Position: PRESIDENT OF CORP
Credential: DDS
Phone: 320-252-2454