Basic Information
| Provider Information | |||||||||
| NPI: | 1427549674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N 34TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153955380 | ||||||||
| FaxNumber: | 7153942682 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 TOWER AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153921955 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2018 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D14018 | MN | N | Dental Providers | Dentist | General Practice | 1223G0001X | 1001853 | WI | Y | Dental Providers | Dentist | General Practice |
No ID Information.