Provider Demographics
NPI:1366539082
Name:MATTHEW J PETERSON, DDS, PA
Entity type:Organization
Organization Name:MATTHEW J PETERSON, DDS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-689-1554
Mailing Address - Street 1:124 1ST AVE E
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1209
Mailing Address - Country:US
Mailing Address - Phone:763-689-1554
Mailing Address - Fax:
Practice Address - Street 1:124 1ST AVE E
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1209
Practice Address - Country:US
Practice Address - Phone:763-689-1554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11782261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN307G4CAOtherBLUE CROSS BLUE SHIELD
MN7845201OtherMN TAX ID #
MN307G4CAOtherBLUE CROSS BLUE SHIELD