Provider Demographics
NPI:1184840365
Name:PETERSEN, STEVEN BLAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:BLAINE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9202 202ND ST W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7915
Mailing Address - Country:US
Mailing Address - Phone:952-469-2818
Mailing Address - Fax:952-469-2566
Practice Address - Street 1:9202 202ND ST W
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7915
Practice Address - Country:US
Practice Address - Phone:952-469-2818
Practice Address - Fax:952-469-2566
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice