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General NPI Number Information
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NPI Number | 1073653689
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Entity Type | Individual
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Provider Name | REX J. PETERSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 03/22/2017
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Provider Practice Location Address
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Address Line | 5640 WASATCH DR STE C
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City | OGDEN
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State | UT
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Zip | 84403-4993
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Country | US
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Telephone | 801-479-9443
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Fax |
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Provider Business Mailing Address
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Address Line | 5640 WASATCH DR STE C
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City | OGDEN
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State | UT
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Zip | 84403-4993
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Country | US
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Telephone | 801-479-9443
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 140013-9921
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License Number State | UT
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