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General NPI Number Information
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NPI Number | 1457806457
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Entity Type | Individual
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Provider Name | TYSON DON PETERSEN D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1260 N 200 E
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City | LOGAN
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State | UT
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Zip | 84341-7560
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Country | US
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Telephone | 435-752-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 763 E 350 S
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City | SMITHFIELD
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State | UT
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Zip | 84335-1325
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Country | US
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Telephone | 435-730-6233
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4774
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10387670-9923
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License Number State | UT
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