Provider Demographics
NPI:1760684559
Name:PETERS, SALLY NICOLE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:NICOLE
Last Name:PETERS
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 COMMERCE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-5702
Mailing Address - Country:US
Mailing Address - Phone:651-578-8401
Mailing Address - Fax:651-528-8080
Practice Address - Street 1:707 COMMERCE DR STE 110
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5702
Practice Address - Country:US
Practice Address - Phone:651-578-8401
Practice Address - Fax:651-528-8080
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND110281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics