Provider Demographics
NPI:1568624690
Name:DEVRIES, BRADLEY EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:EDWARD
Last Name:DEVRIES
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 1:433 SERENITY OAK LN UNIT B
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2300
Mailing Address - Country:US
Mailing Address - Phone:801-694-3106
Mailing Address - Fax:
Practice Address - Street 1:575 UNIVERSITY PKWY
Practice Address - Street 2:SUITE I-163
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7400
Practice Address - Country:US
Practice Address - Phone:801-426-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6945665-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist