Provider Demographics
NPI:1366950602
Name:PETERSON, DANIELLE (DDS)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
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:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-1440
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:880 HERRIOT DR
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-2031
Practice Address - Country:US
Practice Address - Phone:608-847-6700
Practice Address - Fax:608-847-6122
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001742-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice