Healthcare Provider Details

I. General information

NPI: 1699049627
Provider Name (Legal Business Name): CORY PETERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3813 S KIWANIS CIR
SIOUX FALLS SD
57105-4266
US

IV. Provider business mailing address

3813 S KIWANIS CIR
SIOUX FALLS SD
57105-4266
US

V. Phone/Fax

Practice location:
  • Phone: 605-332-1095
  • Fax:
Mailing address:
  • Phone: 605-332-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7015
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR668
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD1227
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: