Healthcare Provider Details

I. General information

NPI: 1598128084
Provider Name (Legal Business Name): DR. BRETT BALLINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W 5600 S
OGDEN UT
84405-6867
US

IV. Provider business mailing address

285 W 5600 S
OGDEN UT
84405
US

V. Phone/Fax

Practice location:
  • Phone: 801-668-7251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9791650-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: