MEDICARE: DR. BRADFORD DANIEL BOWEN DDS

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	1444899923	UT
2	1223G0001X	General Practice Dentistry	144489-9923	UT

General Provider Information

NPI Number	:	1295830651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADFORD DANIEL BOWEN DDS

Provider Business Mailing Address
First Line	:	1356 SOUTH 2100 EAST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108
Country	:	US
Telephone Number	:	801-581-0054
Fax Number	:	801-581-0548

Provider Business Practice Location Address
First Line	:	1356 SOUTH 2100 EAST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108
Country	:	US
Telephone Number	:	801-581-0054
Fax Number	:	801-581-0548

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	02/11/2016

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