Provider Demographics
NPI:1083684815
Name:BRONSON, MICHAEL ROY (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:BRONSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 S 1840 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8549
Mailing Address - Country:US
Mailing Address - Phone:801-710-8774
Mailing Address - Fax:801-728-9109
Practice Address - Street 1:1448 N 2000 W
Practice Address - Street 2:SUITE #6
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8377
Practice Address - Country:US
Practice Address - Phone:801-728-3924
Practice Address - Fax:801-728-9109
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5346717-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528564603001Medicaid