Healthcare Provider Details

I. General information

NPI: 1164532073
Provider Name (Legal Business Name): DENNIS R PETERSON M.D.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MEDICAL DR SUITE B200
BOUNTIFUL UT
84010-4946
US

IV. Provider business mailing address

PO BOX 307
BOUNTIFUL UT
84011-0307
US

V. Phone/Fax

Practice location:
  • Phone: 801-292-7254
  • Fax: 801-295-5494
Mailing address:
  • Phone: 801-294-6907
  • Fax: 801-294-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number158238-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: