MEDICARE: PETERSON DENTAL PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1669046199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON DENTAL PA

Provider Business Mailing Address
First Line	:	1579 HAMLINE AVE N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55108-6119
Country	:	US
Telephone Number	:	651-646-8851
Fax Number	:	651-646-4477

Provider Business Practice Location Address
First Line	:	1579 HAMLINE AVE N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55108-6119
Country	:	US
Telephone Number	:	651-646-8851
Fax Number	:	651-646-4477

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD PETERSON
Credential	:	DDS
Telephone Number	:	651-646-8851

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	05/19/2021

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Directions to “PETERSON DENTAL PA ” Practice Location

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