Provider Demographics
NPI:1124663109
Name:DEGALLIER, PETER ROLAND (DENTAL THERAPIST)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:ROLAND
Last Name:DEGALLIER
Suffix:
Gender:M
Credentials:DENTAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 E HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-5300
Mailing Address - Country:US
Mailing Address - Phone:507-452-9453
Mailing Address - Fax:
Practice Address - Street 1:720 E HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-5300
Practice Address - Country:US
Practice Address - Phone:507-452-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT117125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes125J00000XDental ProvidersDental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1497784342OtherNPI
MN1992930556OtherNPI
MN1801957758OtherNPI