Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 5130379-9922 | UT |
NPI | 1003942335 |
---|---|
Provider Name | Dr. Douglas A Petersen |
First Address | Nephi, UT 84648-1558 |
Second Address | Nephi, UT 84648-1558 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2007 |
Last Update Date | 08/07/2007 |