Provider Demographics
NPI:1639250673
Name:GLADWELL, MICHAEL A (DMD, MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GLADWELL
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 S 1100 E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1213
Mailing Address - Country:US
Mailing Address - Phone:801-262-7447
Mailing Address - Fax:
Practice Address - Street 1:3920 S 1100 E
Practice Address - Street 2:SUITE 150
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1213
Practice Address - Country:US
Practice Address - Phone:801-262-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12291204E00000X
UT347697-9924204E00000X
MN54113204E00000X
UT347697-1205204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33828100Medicaid
MNENROLLEDMedicaid
MN935190000Medicaid
MNV10812Medicare UPIN
MN850000129Medicare PIN
WI33828100Medicaid