Provider Demographics
NPI:1548297039
Name:PEDERSON, MICHAEL TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TODD
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 MICHIGAN AVENUE WEST
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MN
Mailing Address - Zip Code:56484-1389
Mailing Address - Country:US
Mailing Address - Phone:218-547-1851
Mailing Address - Fax:218-547-2261
Practice Address - Street 1:108 MICHIGAN AVENUE WEST
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-1389
Practice Address - Country:US
Practice Address - Phone:218-547-1851
Practice Address - Fax:218-547-2261
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND112521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice