Provider Demographics
NPI:1457513616
Name:PETERSON, RUSSELL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:THOMAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 W SAINT GERMAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4502
Mailing Address - Country:US
Mailing Address - Phone:320-252-2454
Mailing Address - Fax:320-252-2232
Practice Address - Street 1:816 W SAINT GERMAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4502
Practice Address - Country:US
Practice Address - Phone:320-252-2454
Practice Address - Fax:320-252-2232
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist