Provider Demographics
NPI:1437688694
Name:NIELSEN, BRADY BENJAMIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:BENJAMIN
Last Name:NIELSEN
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 1:3759 W 850 S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9807
Mailing Address - Country:US
Mailing Address - Phone:801-686-7836
Mailing Address - Fax:
Practice Address - Street 1:880 HERITAGE PARK BLVD STE 220
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5680
Practice Address - Country:US
Practice Address - Phone:801-728-4688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10383844-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice