MEDICARE: DR. BRADY MICHAEL THOMSON 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	4804772-9921	UT
2	1223G0001X	General Practice Dentistry	4804772-9921	UT

General Provider Information

NPI Number	:	1912998725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADY MICHAEL THOMSON DDS

Provider Business Mailing Address
First Line	:	1624 N 200 E STE 120
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-3141
Country	:	US
Telephone Number	:	435-752-1320
Fax Number	:

Provider Business Practice Location Address
First Line	:	1624 N 200 E STE 120
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-3141
Country	:	US
Telephone Number	:	435-752-1320
Fax Number	:	435-752-1320

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

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	01/03/2022

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