Basic Information
| Provider Information | |||||||||
| NPI: | 1477566198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | THAD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2162 E. CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840936448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019422631 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | GEORGE E WAHLEN DEPT OF VETERANS AFFAIRS MEDICAL CTR | ||||||||
| Address2: | 500 FOOTHILL DRIVE, DENTAL SERVICE (160) | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015841206 | ||||||||
| FaxNumber: | 8015841251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 135438-9923 | UT | Y | Dental Providers | Dentist | General Practice |
No ID Information.