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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