Provider Demographics
NPI:1295931046
Name:PETERSEN, SCOTT WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N 400 E
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-1558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:435-623-7137
Practice Address - Street 1:310 N 400 E
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-1558
Practice Address - Country:US
Practice Address - Phone:435-623-1916
Practice Address - Fax:435-623-7137
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6508547-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice