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General NPI Number Information
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NPI Number | 1225126063
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Entity Type | Individual
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Provider Name | JEROME WAYNE PEDERSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 08/20/2007
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Provider Practice Location Address
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Address Line | 1515 E 25TH ST C-153 HIBBING COMMUNITY COLLEGE
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City | HIBBING
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State | MN
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Zip | 55746-3354
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Country | US
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Telephone | 218-263-2918
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Fax |
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Provider Business Mailing Address
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Address Line | 1515 E 25TH ST ROOM C-153
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City | HIBBING
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State | MN
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Zip | 55746-3354
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D8426
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License Number State | MN
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