Provider Demographics
NPI:1205995594
Name:PETERSON, KARI LEE (DENTIST DDS)
Entity type:Individual
Prefix:MRS
First Name:KARI
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DENTIST DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 THEILMAN LANE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301
Mailing Address - Country:US
Mailing Address - Phone:320-252-4126
Mailing Address - Fax:320-202-6507
Practice Address - Street 1:4140 THEILMAN LANE
Practice Address - Street 2:SUITE 208
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301
Practice Address - Country:US
Practice Address - Phone:320-252-4126
Practice Address - Fax:320-202-6507
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8397078OtherSTATE ID