Provider Demographics
NPI:1124313143
Name:PETERSON, KATIE LOUISE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:LOUISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 ANNE ST NW
Mailing Address - Street 2:NORTHERN DENTAL ACCESS CENTER
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5113
Mailing Address - Country:US
Mailing Address - Phone:218-444-9646
Mailing Address - Fax:218-444-9252
Practice Address - Street 1:1405 ANNE ST NW
Practice Address - Street 2:NORTHERN DENTAL ACCESS CENTER
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5113
Practice Address - Country:US
Practice Address - Phone:218-444-9646
Practice Address - Fax:218-444-9252
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist