Provider Demographics
NPI:1407902307
Name:PETERSEN, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:3101 OLD HIGHWAY 8
Mailing Address - Street 2:SUITE #303
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1072
Mailing Address - Country:US
Mailing Address - Phone:651-636-0840
Mailing Address - Fax:651-633-1760
Practice Address - Street 1:3101 OLD HIGHWAY 8
Practice Address - Street 2:SUITE #303
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1072
Practice Address - Country:US
Practice Address - Phone:651-636-0840
Practice Address - Fax:651-633-1760
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN(NEED TYPE 2 # ALSO)Other(INCORPORATED)HAVE IND.#