Healthcare Provider Details

I. General information

NPI: 1568624690
Provider Name (Legal Business Name): BRADLEY EDWARD DEVRIES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 W 12600 S STE 104
RIVERTON UT
84065-7130
US

IV. Provider business mailing address

1291 W 12600 S STE 104
RIVERTON UT
84065-7130
US

V. Phone/Fax

Practice location:
  • Phone: 801-254-4161
  • Fax:
Mailing address:
  • Phone: 801-254-4161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6945665-9923
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6945665-9923
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: