Provider Demographics
NPI:1184895351
Name:PETER H MIELKE DDS PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:PETER H MIELKE DDS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:HERMANN
Authorized Official - Last Name:MIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-779-9002
Mailing Address - Street 1:1675 BEAM AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1479
Mailing Address - Country:US
Mailing Address - Phone:651-779-9002
Mailing Address - Fax:
Practice Address - Street 1:1675 BEAM AVE STE 202
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1479
Practice Address - Country:US
Practice Address - Phone:651-779-9002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty