MEDICARE: THOMSON ORTHODONTICS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8041458	UT
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	4804772	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1821130253	OTHER	UT	INDIVIDUAL NPI
2	1912998725	OTHER	UT	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1285181131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMSON ORTHODONTICS

Provider Business Mailing Address
First Line	:	1445 N 400 E STE 3
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-7564
Country	:	US
Telephone Number	:	435-752-1320
Fax Number	:	435-750-6432

Provider Business Practice Location Address
First Line	:	1445 N 400 E STE 3
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-7564
Country	:	US
Telephone Number	:	435-752-1320
Fax Number	:	435-750-6432

Authorized Official
Title or Position	:	OWNER/ORTHODONTIST
Name	:	BRADY THOMSON
Credential	:	D.D.S.
Telephone Number	:	435-752-1320

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	09/08/2016

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Directions to “THOMSON ORTHODONTICS ” Practice Location

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