Provider Demographics
NPI:1902118557
Name:BRYAN E GOTTFREDSON DDS
Entity Type:Organization
Organization Name:BRYAN E GOTTFREDSON DDS
Other - Org Name:MAIN STREET DENTAL OF MAGNA
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:ELDEN
Authorized Official - Last Name:GOTTFREDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-250-7311
Mailing Address - Street 1:9010 W 2700 S
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-1002
Mailing Address - Country:US
Mailing Address - Phone:801-250-7311
Mailing Address - Fax:801-250-3801
Practice Address - Street 1:9010 W 2700 S
Practice Address - Street 2:
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-1002
Practice Address - Country:US
Practice Address - Phone:801-250-7311
Practice Address - Fax:801-250-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT360010-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty