Provider Demographics
NPI:1184835027
Name:PETERSEN DENTAL CLINIC PA
Entity type:Organization
Organization Name:PETERSEN DENTAL CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-461-5113
Mailing Address - Street 1:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MN
Mailing Address - Zip Code:55054-0136
Mailing Address - Country:US
Mailing Address - Phone:952-461-5113
Mailing Address - Fax:
Practice Address - Street 1:730 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ELKO
Practice Address - State:MN
Practice Address - Zip Code:55020-9701
Practice Address - Country:US
Practice Address - Phone:952-461-5113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty