Provider Demographics
NPI:1629046743
Name:PETERSON, NATALIE A (DDS)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:A
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 1:13550 26TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3650
Mailing Address - Country:US
Mailing Address - Phone:651-557-0287
Mailing Address - Fax:
Practice Address - Street 1:13550 26TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3650
Practice Address - Country:US
Practice Address - Phone:651-557-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5600015122300000X
MND11685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist