Provider Demographics
NPI:1053935916
Name:MICHAEL J. PETERSEN, D.D.S., P.A.
Entity type:Organization
Organization Name:MICHAEL J. PETERSEN, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-636-0840
Mailing Address - Street 1:3101 OLD HIGHWAY 8 STE 303
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1076
Mailing Address - Country:US
Mailing Address - Phone:651-636-0840
Mailing Address - Fax:
Practice Address - Street 1:3101 OLD HIGHWAY 8 STE 303
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1076
Practice Address - Country:US
Practice Address - Phone:651-636-0840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental