Healthcare Provider Details

I. General information

NPI: 1093093312
Provider Name (Legal Business Name): BRADEN CORDELL ATKINS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 S 4000 W STE B
WEST VALLEY CITY UT
84120-6250
US

IV. Provider business mailing address

617 W 1825 N
CENTERVILLE UT
84014-3148
US

V. Phone/Fax

Practice location:
  • Phone: 216-264-6804
  • Fax:
Mailing address:
  • Phone: 801-201-7429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9017911-9924
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: