Robert Melvin Pederson, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

4062-015 Issued in WI

Practice address

853 W Main St
Mondovi, WI 54755-1429

Phone

(715) 926-6035

NPI assigned

Aug 25, 2006

Last updated

Jul 9, 2007By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156464000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1063529808",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "853 W MAIN ST",
            "city": "MONDOVI",
            "state": "WI",
            "postal_code": "547551429",
            "telephone_number": "715-926-6035"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "853 W MAIN ST",
            "city": "MONDOVI",
            "state": "WI",
            "postal_code": "547551429",
            "telephone_number": "715-926-6035"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PEDERSON",
        "first_name": "ROBERT",
        "middle_name": "MELVIN",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-08-25",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WI",
            "license": "4062-015",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33687500",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Nancy Polzer Hearing Aid Services
• Jenna Ruth Nehls, PHARMD
• Nancy Alice Olson-Bauer, P.T.
• Sandra J Packard, NP
• Lisa Jane Palecek, IHP
• Pharmacare LTD (Mondovi Pharmacy)
• Pharmacare LTD (Mondovi Pharmacy)
• Desiree Phillips, PA
• Alexandria Pinkos
• Jennifer E Plaetz, PT

• General Practice Dentistry in Mondovi, WI
• Providers in Mondovi, WI by specialty
• General Practice Dentistry in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.