Provider Demographics
NPI:1336450816
Name:PETERSEN, LUKE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:R
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 1:1694 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2559
Mailing Address - Country:US
Mailing Address - Phone:801-560-6284
Mailing Address - Fax:
Practice Address - Street 1:3078 W 7800 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-3707
Practice Address - Country:US
Practice Address - Phone:801-280-1911
Practice Address - Fax:801-255-2394
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7702761-99021122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist