Individual
DR. MATTHEW J PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
135 OPPORTUNITY S BLVD, CAMBRIDGE, MN 55008
(763) 689-1554
Mailing address
135 OPPORTUNITY S BLVD, CAMBRIDGE, MN 55008
(763) 689-1554
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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