Provider Demographics
NPI:1346597507
Name:J. DAYNE PETERSEN M.D., PC
Entity Type:Organization
Organization Name:J. DAYNE PETERSEN M.D., PC
Other - Org Name:NUVISTA PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DAYNE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-971-8684
Mailing Address - Street 1:5353 S 960 E
Mailing Address - Street 2:#150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-3569
Mailing Address - Country:US
Mailing Address - Phone:801-261-5791
Mailing Address - Fax:801-747-7740
Practice Address - Street 1:5353 S 960 E
Practice Address - Street 2:#150
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-3569
Practice Address - Country:US
Practice Address - Phone:801-261-5791
Practice Address - Fax:801-747-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT83185641205261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty