Provider Demographics
NPI:1003966169
Name:PETERSON, ELDEN WALTER (DDS)
Entity Type:Individual
Prefix:
First Name:ELDEN
Middle Name:WALTER
Last Name:PETERSON
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 1:9269 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6572
Mailing Address - Country:US
Mailing Address - Phone:801-566-4153
Mailing Address - Fax:801-566-1963
Practice Address - Street 1:9269 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6572
Practice Address - Country:US
Practice Address - Phone:801-566-4153
Practice Address - Fax:801-566-1963
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1307709922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist