Provider Demographics
NPI:1972121770
Name:DR. TYSON PETERESN
Entity Type:Organization
Organization Name:DR. TYSON PETERESN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-752-0300
Mailing Address - Street 1:110 E 200 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4007
Mailing Address - Country:US
Mailing Address - Phone:435-752-0300
Mailing Address - Fax:735-755-7625
Practice Address - Street 1:110 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4007
Practice Address - Country:US
Practice Address - Phone:435-752-0300
Practice Address - Fax:435-755-7625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPE1OtherDENTAL