MEDICARE: DR. BRYAN E GOTTFREDSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	360010	UT

General Provider Information

NPI Number	:	1174501688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN E GOTTFREDSON DDS

Provider Business Mailing Address
First Line	:	9010 W 2700 S
Second Line	:
City	:	MAGNA
State	:	UT
Zip	:	84044-1002
Country	:	US
Telephone Number	:	801-250-7311
Fax Number	:	801-250-3801

Provider Business Practice Location Address
First Line	:	9010 W 2700 S
Second Line	:
City	:	MAGNA
State	:	UT
Zip	:	84044-1002
Country	:	US
Telephone Number	:	801-250-7311
Fax Number	:	801-250-3801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/12/2010

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