Provider Demographics
NPI:1760428593
Name:PETERSON, WILLIAM H (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
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 1:917 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347
Mailing Address - Country:US
Mailing Address - Phone:320-732-6141
Mailing Address - Fax:320-732-6543
Practice Address - Street 1:917 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347
Practice Address - Country:US
Practice Address - Phone:320-732-6141
Practice Address - Fax:320-732-6543
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist