Tyson Don Petersen, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

10387670-9923 Issued in UT

Practice address

1260 N 200 E
Logan, UT 84341-7560

Phone

(435) 752-8000

NPI assigned

Aug 18, 2016

Last updated

Jul 21, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in ID

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Dr. Tyson Peteresn

  • Dental Clinic/Center
  • Logan, UT
  • NPI 1972121770
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1471478400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658361600000",
    "number": "1457806457",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "763 E 350 S",
            "city": "SMITHFIELD",
            "state": "UT",
            "postal_code": "843351325",
            "telephone_number": "435-730-6233"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1260 N 200 E",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843417560",
            "telephone_number": "435-752-8000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "TYSON",
        "middle_name": "DON",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-08-18",
        "last_updated": "2022-07-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "ID",
            "license": "4774",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "UT",
            "license": "10387670-9923",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mark Perkins
• Rilee Diane Perrett, LCSW
• Jenika A. Perry, CSW
• Chase B Petersen, M.D.
• Kent H Petersen, PHARM.D.
• Ashley Elizabeth Peterson, FNP-BC
• Brent E. Peterson, D.C.
• Cameron Glade Peterson, M.D.
• David Erik Peterson, MD
• Frank E Peterson, M.D.

• General Practice Dentistry in Logan, UT
• Providers in Logan, UT by specialty
• General Practice Dentistry in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.