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General NPI Number Information
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NPI Number | 1750574810
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Entity Type | Organization
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Legal Business Name | PERIODONTAL SPECIALISTS
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Dates
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Enumeration Date | 08/22/2007
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Last Update Date | 08/22/2007
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Provider Practice Location Address
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Address Line | 754 S MAIN ST STE 7
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City | ST GEORGE
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State | UT
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Zip | 84770-5517
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Country | US
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Telephone | 435-652-1605
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Fax | 435-652-2046
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Provider Business Mailing Address
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Address Line | 754 S MAIN ST STE 7
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City | ST GEORGE
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State | UT
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Zip | 84770-5517
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Country | US
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Telephone | 435-652-1605
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Fax | 435-652-2046
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Authorized Official
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Title or Position | PERIODONTIST
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Name | THOMAS L BRADSHAW
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Credential | DDS
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Telephone | 435-652-1605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 275219
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License Number State | UT
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