Provider Demographics
NPI:1164688800
Name:WALKER, BRADLEY STEPHEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:STEPHEN
Last Name:WALKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 E 4500 S STE 102
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4252
Mailing Address - Country:US
Mailing Address - Phone:801-273-5632
Mailing Address - Fax:
Practice Address - Street 1:1434 E 4500 S STE 102
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4252
Practice Address - Country:US
Practice Address - Phone:801-273-5632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7030084-9922122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist