Provider Demographics
NPI:1770649832
Name:PETERSON, GREGORY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
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 1:800 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1651
Mailing Address - Country:US
Mailing Address - Phone:507-831-2538
Mailing Address - Fax:
Practice Address - Street 1:800 5TH AVE
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1651
Practice Address - Country:US
Practice Address - Phone:507-831-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN8302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist