Matthew J Peterson, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

11782 Issued in MN

Practice address

135 Opportunity S Blvd
Cambridge, MN 55008

Phone

(763) 689-1554

NPI assigned

Oct 6, 2006

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 3

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

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

{
    "created_epoch": "1160092800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1445212800000",
    "number": "1902993629",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "135 OPPORTUNITY S BLVD",
            "city": "CAMBRIDGE",
            "state": "MN",
            "postal_code": "55008",
            "telephone_number": "763-689-1554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "135 OPPORTUNITY S BLVD",
            "city": "CAMBRIDGE",
            "state": "MN",
            "postal_code": "55008",
            "telephone_number": "763-689-1554"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "MATTHEW",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-10-06",
        "last_updated": "2015-10-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "11782",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FED TAX ID #",
            "identifier": "20-2797371",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "307G4CA",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MN TAX ID #",
            "identifier": "7845201",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kristin Peltz
• Stuart R Pemberton, MD
• Abbe Jennifer Penziner-Bokde, MD
• McKenzie Lynn Perkins
• Margaret Mary Peterson
• Samantha Peterson
• Stephanie Peterson, M.A.
• McKenzie Adeline Petschl
• Charles J Phillips, MD
• PHS/Cambridge Care Center, LLC

• General Practice Dentistry in Cambridge, MN
• Providers in Cambridge, MN by specialty
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2015; 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.