Russell Thomas Peterson, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

D12530 Issued in MN

Practice address

816 W Saint Germain St
Suite 101
Saint Cloud, MN 56301-4502

Phone

(320) 252-2454

Fax

(320) 252-2232

NPI assigned

Jun 30, 2008

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

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

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Peterson Dental Associates, P.a.

  • General Practice Dentistry
  • St Cloud, MN
  • NPI 1396856100
  NPD (past) Authorized official
• St. Cloud Family Dental PLLC

  • Dental Clinic/Center
  • Saint Cloud, MN
  • NPI 1699525915
  NPD (past)

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

{
    "created_epoch": "1214784000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1242259200000",
    "number": "1457513616",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "816 W SAINT GERMAIN ST",
            "address_2": "SUITE 101",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563014502",
            "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 SAINT GERMAIN ST",
            "address_2": "SUITE 101",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563014502",
            "telephone_number": "320-252-2454",
            "fax_number": "320-252-2232"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "RUSSELL",
        "middle_name": "THOMAS",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-06-30",
        "last_updated": "2009-05-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "MN",
            "license": "D12530",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Matthew J Peterson, LMFT
• Michelle Joan Peterson, RN CAGNP
• Nicole E Peterson, P.T.
• Paul Charles Peterson, MD
• Richard Allen Peterson, RN
• Shaina Peterson, SLP
• Susan A Peterson, CRNA
• Tara Peterson
• Theodore A Peterson, M.D.
• Thomas M Peterson, PT

• All providers in Saint Cloud, MN
• Dentist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 14, 2009; 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.