Provider Demographics
NPI:1508094244
Name:PETERSON, ELISABETH M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2500 COMO AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1460
Mailing Address - Country:US
Mailing Address - Phone:651-999-4600
Mailing Address - Fax:651-632-8984
Practice Address - Street 1:2500 COMO AVENUE
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1460
Practice Address - Country:US
Practice Address - Phone:651-999-4600
Practice Address - Fax:651-632-8984
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery