Provider Demographics
NPI:1174501688
Name:GOTTFREDSON, BRYAN E (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:E
Last Name:GOTTFREDSON
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 1:9010 W 2700 S
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-1002
Mailing Address - Country:US
Mailing Address - Phone:801-250-7311
Mailing Address - Fax:801-250-3801
Practice Address - Street 1:9010 W 2700 S
Practice Address - Street 2:
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-1002
Practice Address - Country:US
Practice Address - Phone:801-250-7311
Practice Address - Fax:801-250-3801
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3600101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice