Provider Demographics
NPI:1609935097
Name:PETERSON, DONALD JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JOSEPH
Last Name:PETERSON
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 1:1901 SIMPSON ST
Mailing Address - Street 2:
Mailing Address - City:FALCON HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6145
Mailing Address - Country:US
Mailing Address - Phone:651-644-9590
Mailing Address - Fax:
Practice Address - Street 1:1579 HAMLINE AVE N
Practice Address - Street 2:
Practice Address - City:FALCON HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55108-2107
Practice Address - Country:US
Practice Address - Phone:651-646-8851
Practice Address - Fax:651-646-4477
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist