Provider Demographics
NPI:1043485865
Name:PETERSON, STEVEN R (DDS SC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TAINTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-8200
Mailing Address - Country:US
Mailing Address - Phone:715-235-4291
Mailing Address - Fax:715-235-4292
Practice Address - Street 1:1700 TAINTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-8200
Practice Address - Country:US
Practice Address - Phone:715-235-4291
Practice Address - Fax:715-235-4292
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6154-0151223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice