Provider Demographics
NPI:1699049627
Name:PETERSON, CORY (DDS)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3813 S KIWANIS CIR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4266
Mailing Address - Country:US
Mailing Address - Phone:605-332-1095
Mailing Address - Fax:
Practice Address - Street 1:3813 S KIWANIS CIR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4266
Practice Address - Country:US
Practice Address - Phone:605-332-1095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7015122300000X
MNR668390200000X
SDD12271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program