Provider Demographics
NPI:1598967382
Name:PETERS ORTHODONTIC SPECIALISTS
Entity Type:Organization
Organization Name:PETERS ORTHODONTIC SPECIALISTS
Other - Org Name:DR. NICOLE PETERS ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:651-578-8401
Mailing Address - Street 1:1099 HELMO AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6037
Mailing Address - Country:US
Mailing Address - Phone:651-578-8401
Mailing Address - Fax:651-731-6836
Practice Address - Street 1:1099 HELMO AVE N STE 200
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6037
Practice Address - Country:US
Practice Address - Phone:651-578-8401
Practice Address - Fax:651-731-6836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND110281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty