Provider Demographics
NPI:1437715182
Name:PETERSON, JAMIE LEE (DDS)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LEE
Other - Last Name:ST.MARIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5400 140TH AVE NW STE 104
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-3949
Mailing Address - Country:US
Mailing Address - Phone:763-427-8117
Mailing Address - Fax:
Practice Address - Street 1:5400 140TH AVE NW STE 104
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-3949
Practice Address - Country:US
Practice Address - Phone:763-427-8117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist