Provider Demographics
NPI:1164580197
Name:POULSEN, GERALD PARKER (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:PARKER
Last Name:POULSEN
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 1:3105 W 5400 S
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2200
Mailing Address - Country:US
Mailing Address - Phone:801-969-6236
Mailing Address - Fax:801-966-4572
Practice Address - Street 1:3105 W 5400 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-2200
Practice Address - Country:US
Practice Address - Phone:801-969-6236
Practice Address - Fax:801-966-4572
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT131024-99211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics