Provider Demographics
NPI:1427036714
Name:PETERSON, TANYA SCHULZ (DDS)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:SCHULZ
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W. BURNSVILLE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-890-2791
Mailing Address - Fax:952-277-0200
Practice Address - Street 1:550 W. BURNSVILLE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-890-2791
Practice Address - Fax:952-277-0200
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN299317100Medicaid
MN28012SCOtherBCBS