NPIMap

Organization Active NPI

Peterson Dental Associates, P.a.

  • General Practice Dentistry
  • Saint Cloud, MN
National Provider Identifier
1396856100
Registry record updated Jun 17, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
PETERSON DENTAL ASSOCIATES, P.A.
Practice address
816 W St Germain St #101
St Cloud, MN 56301-3511
Phone
(320) 252-2454
Fax
(320) 252-2232
NPI assigned
Aug 31, 2006
Last updated
Jun 17, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2014

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

Authorized official

Name
Mr. Russell Thomas Peterson, DDSNPI 1457513616
Title
President of Corp
Phone
(320) 252-2454

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X Primary
Dental Hygienist 124Q00000X
Dental Assistant 126800000X

Addresses

Primary practice location

816 W St Germain St #101
St Cloud, MN 56301-3511

Mailing address

816 W St Germain St #101
St Cloud, MN 56301-3511
Phone (320) 252-2454

Other identifiers 1

IdentifierTypeStateIssuer
398350100MedicaidMN

National Provider Directory

National Provider Directory

Locations

816 W Saint Germain St
Ste 101
Saint Cloud, MN 56301
Phone (320) 252-2454

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402963200000",
    "number": "1396856100",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "816 W ST GERMAIN ST #101",
            "city": "ST CLOUD",
            "state": "MN",
            "postal_code": "563013511",
            "telephone_number": "320-252-2454",
            "fax_number": "320-252-2232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "816 W ST GERMAIN ST #101",
            "city": "ST CLOUD",
            "state": "MN",
            "postal_code": "563013511",
            "telephone_number": "320-252-2454",
            "fax_number": "320-252-2232"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSON DENTAL ASSOCIATES, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-31",
        "last_updated": "2014-06-17",
        "status": "A",
        "authorized_official_last_name": "PETERSON",
        "authorized_official_first_name": "RUSSELL",
        "authorized_official_middle_name": "THOMAS",
        "authorized_official_title_or_position": "PRESIDENT OF CORP",
        "authorized_official_telephone_number": "320-252-2454",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "126800000X",
            "taxonomy_group": "",
            "desc": "Dental Assistant",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "398350100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Cloud, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.