Provider Demographics
NPI:1508422411
Name:PETERSEN, JOHN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
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 1:3200 HILLDALE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2502
Mailing Address - Country:US
Mailing Address - Phone:612-790-3615
Mailing Address - Fax:
Practice Address - Street 1:4555 ERIN DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3398
Practice Address - Country:US
Practice Address - Phone:651-681-9044
Practice Address - Fax:651-681-0599
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND139931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice