Provider Demographics
NPI:1326335092
Name:PETER C. KNUDSON DDS, MS, PC
Entity Type:Organization
Organization Name:PETER C. KNUDSON DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, PC
Authorized Official - Phone:435-723-6366
Mailing Address - Street 1:105 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3108
Mailing Address - Country:US
Mailing Address - Phone:435-723-6366
Mailing Address - Fax:435-723-6371
Practice Address - Street 1:105 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3108
Practice Address - Country:US
Practice Address - Phone:435-723-6366
Practice Address - Fax:435-723-6371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529449844016Medicaid