Provider Demographics
NPI:1659582237
Name:MOUNTAIN VALLEY DENTAL- PETERSEN, LLC
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY DENTAL- PETERSEN, LLC
Other - Org Name:DAVID E. PETERSEN DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR MANAGEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-573-5572
Mailing Address - Street 1:1025 E 11400 S
Mailing Address - Street 2:102
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-6942
Mailing Address - Country:US
Mailing Address - Phone:801-576-8696
Mailing Address - Fax:801-576-8466
Practice Address - Street 1:1025 E 11400 S
Practice Address - Street 2:102
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-6942
Practice Address - Country:US
Practice Address - Phone:801-576-8696
Practice Address - Fax:801-576-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty