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Organization
PETERSON DENTAL ASSOCIATES, P.A.
Active
Organization
PETERSON DENTAL ASSOCIATES, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL THOMAS PETERSON DDS (PRESIDENT OF CORP)
(320) 252-2454
Entity
Organization
Contact information
Practice address
816 W ST GERMAIN ST #101, ST CLOUD, MN 56301-3511
(320) 252-2454
(320) 252-2232
Mailing address
816 W ST GERMAIN ST #101, ST CLOUD, MN 56301-3511
(320) 252-2454
(320) 252-2232
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
124Q00000X
Dental Hygienist
—
—
126800000X
Dental Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
398350100
—
MN
Enumeration date
08/31/2006
Last updated
06/17/2014
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