Provider Demographics
NPI:1720199953
Name:PETERSEN FAMILY DENTAL CLINIC PA
Entity Type:Organization
Organization Name:PETERSEN FAMILY DENTAL CLINIC PA
Other - Org Name:ELKO-NEW MARKET DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-469-2818
Mailing Address - Street 1:9202 202ND ST W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7915
Mailing Address - Country:US
Mailing Address - Phone:952-469-2818
Mailing Address - Fax:952-469-2566
Practice Address - Street 1:9202 202ND ST W
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7915
Practice Address - Country:US
Practice Address - Phone:952-469-2818
Practice Address - Fax:952-469-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty