Provider Demographics
NPI:1225126063
Name:PEDERSEN, JEROME WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:WAYNE
Last Name:PEDERSEN
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 1:1515 E 25TH ST
Mailing Address - Street 2:ROOM C-153
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 E 25TH ST
Practice Address - Street 2:C-153 HIBBING COMMUNITY COLLEGE
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3354
Practice Address - Country:US
Practice Address - Phone:218-263-2918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist