Provider Demographics
NPI:1013988765
Name:PETERSON & PETERSON DDS PA
Entity Type:Organization
Organization Name:PETERSON & PETERSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VACHAREE
Authorized Official - Middle Name:SRISWAD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-774-2959
Mailing Address - Street 1:1224 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2021
Mailing Address - Country:US
Mailing Address - Phone:651-774-2959
Mailing Address - Fax:651-774-1997
Practice Address - Street 1:1224 ARCADE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2021
Practice Address - Country:US
Practice Address - Phone:651-774-2959
Practice Address - Fax:651-774-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty