Provider Demographics
NPI:1891806709
Name:PETERSON, THOMAS MERLIN (DDS)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MERLIN
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 1:816 W ST GERMAIN ST #101
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3511
Mailing Address - Country:US
Mailing Address - Phone:320-252-2454
Mailing Address - Fax:320-252-2232
Practice Address - Street 1:816 W ST GERMAIN ST #101
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3511
Practice Address - Country:US
Practice Address - Phone:320-252-2454
Practice Address - Fax:320-252-2232
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND86201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN838318900Medicaid