MEDICARE: DR. ROD J. BRIDGE D.D.S.PERIODONTIST

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	1223P0300X	Periodontics	22150	UT

General Provider Information

NPI Number	:	1174741227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROD J. BRIDGE D.D.S.PERIODONTIST

Provider Business Mailing Address
First Line	:	745 N 500 W
Second Line	:	SUITE 102
City	:	PROVO
State	:	UT
Zip	:	84601-1472
Country	:	US
Telephone Number	:	801-374-8002
Fax Number	:	801-371-0393

Provider Business Practice Location Address
First Line	:	745 N 500 W
Second Line	:	SUITE 102
City	:	PROVO
State	:	UT
Zip	:	84601-1472
Country	:	US
Telephone Number	:	801-374-8002
Fax Number	:	801-371-0393

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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