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Individual
DR. MATTHEW J PETERSON
Active
Individual
DR. MATTHEW J PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
11782
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20-2797371
FED TAX ID #
MN
01
—
307G4CA
BLUE CROSS BLUE SHIELD
MN
01
—
7845201
MN TAX ID #
MN
Enumeration date
10/06/2006
Last updated
10/19/2015
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