Provider Demographics
NPI:1477566198
Name:PETERSEN, BYRON THAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:THAD
Last Name:PETERSEN
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 1:2162 E. CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6448
Mailing Address - Country:US
Mailing Address - Phone:801-942-2631
Mailing Address - Fax:
Practice Address - Street 1:GEORGE E WAHLEN DEPT OF VETERANS AFFAIRS MEDICAL CTR
Practice Address - Street 2:500 FOOTHILL DRIVE, DENTAL SERVICE (160)
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-584-1206
Practice Address - Fax:801-584-1251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT135438-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice