Healthcare Provider Details

I. General information

NPI: 1285253112
Provider Name (Legal Business Name): YULIYA PETUKHOVA MD, DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 E 3900 S STE 104
SALT LAKE CITY UT
84124-1492
US

IV. Provider business mailing address

1377 E 3900 S STE 104
SALT LAKE CITY UT
84124-1492
US

V. Phone/Fax

Practice location:
  • Phone: 801-277-3942
  • Fax:
Mailing address:
  • Phone: 801-277-3942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD14456
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12048924-9926
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14456
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number77495
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number77495
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: