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General NPI Number Information
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NPI Number | 1285161661
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Entity Type | Individual
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Provider Name | KARL JOHN PETERSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 05/17/2017
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Last Update Date | 05/17/2017
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Provider Practice Location Address
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Address Line | 1815 SUBURBAN AVE
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City | SAINT PAUL
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State | MN
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Zip | 55119-4302
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Country | US
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Telephone | 507-285-0449
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Fax |
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Provider Business Mailing Address
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Address Line | 3031 42ND AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55406-2238
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Country | US
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Telephone | 507-285-0449
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D13822
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License Number State | MN
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