Provider Demographics
NPI:1366644668
Name:PETERSON, BURKE B (DDS)
Entity Type:Individual
Prefix:DR
First Name:BURKE
Middle Name:B
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 1:250 E BROADWAY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2418
Mailing Address - Country:US
Mailing Address - Phone:801-322-4082
Mailing Address - Fax:801-322-4082
Practice Address - Street 1:250 E BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2418
Practice Address - Country:US
Practice Address - Phone:801-322-4082
Practice Address - Fax:801-322-4082
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1354461223G0001X
UT378951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice