Provider Demographics
NPI:1386865459
Name:SIMISTER, BRADLEY G (DDS M,SD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:G
Last Name:SIMISTER
Suffix:
Gender:M
Credentials:DDS M,SD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 E RIVERSIDE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4740
Mailing Address - Country:US
Mailing Address - Phone:435-656-3346
Mailing Address - Fax:435-656-9058
Practice Address - Street 1:1054 E RIVERSIDE DR STE 101
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4740
Practice Address - Country:US
Practice Address - Phone:435-656-3346
Practice Address - Fax:435-656-9058
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62212481223X0400X
NVS3-128C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics