Provider Demographics
NPI:1588313134
Name:PETERSON, BRODY WILLIAM
Entity type:Individual
Prefix:
First Name:BRODY
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 1ST ST W STE 215
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5106
Mailing Address - Country:US
Mailing Address - Phone:701-483-6999
Mailing Address - Fax:
Practice Address - Street 1:2 1ST ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5106
Practice Address - Country:US
Practice Address - Phone:701-483-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist