MEDICARE: MICHAEL ROY BRONSON D.D.S.

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	1223G0001X	General Practice Dentistry	5346717-9922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083684815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL ROY BRONSON D.D.S.

Provider Business Mailing Address
First Line	:	1987 S 1840 W
Second Line	:
City	:	SYRACUSE
State	:	UT
Zip	:	84075-8549
Country	:	US
Telephone Number	:	801-710-8774
Fax Number	:	801-728-9109

Provider Business Practice Location Address
First Line	:	1448 N 2000 W
Second Line	:	SUITE #6
City	:	CLINTON
State	:	UT
Zip	:	84015-8377
Country	:	US
Telephone Number	:	801-728-3924
Fax Number	:	801-728-9109

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

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	07/08/2007

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