Paul William Peterson, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D12584 Issued in MN

Practice address

5851 Duluth St
Golden Valley, MN 55422-3946

Phone

(763) 546-1301

NPI assigned

Jun 23, 2008

Last updated

Jun 23, 2008By the provider in NPPES

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

Not listed in the public Medicare enrollment file

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.

Opted out of Medicare

Yes, effective Jul 20, 2022 through Jul 20, 2028

Medicare enrollment (NPD)

Enrolled

Practice roles

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

• Oral & Maxillofacial Surgery Specialists, PA

  dba OMS Specialists

  • Oral and Maxillofacial Surgery (Dentist)
  • Blaine, MN
  • NPI 1467563510
  NPD (past)
• Oral & Maxillofacial Surgery Specialists, PA

  dba OMS Specialists

  • Oral and Maxillofacial Surgery (Dentist)
  • Maple Grove, MN
  • NPI 1902917057
  NPD (past)

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

{
    "created_epoch": "1214179200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1214179200000",
    "number": "1952562803",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5851 DULUTH ST",
            "city": "GOLDEN VALLEY",
            "state": "MN",
            "postal_code": "554223946",
            "telephone_number": "763-546-1301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5851 DULUTH ST",
            "city": "GOLDEN VALLEY",
            "state": "MN",
            "postal_code": "554223946",
            "telephone_number": "763-546-1301"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "PAUL",
        "middle_name": "WILLIAM",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-06-23",
        "last_updated": "2008-06-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D12584",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nergis Petersen, MA, LPCC
• Grace C Peterson, M.D.
• Halie Peterson
• Ioulia Trouskova Peterson, MS, RD, LDN
• Molly Peterson, OTR/L
• Nicole Lynn Pfeffer, COTA/L
• Lucinda S Phair, RN MA MSCN
• Mara Pham, NP
• Branden David Phillips, LICSW
• Jeannine Pamela Phillips, PA-C

• General Practice Dentistry in Golden Valley, MN
• Providers in Golden Valley, 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 Jun 23, 2008; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.