Provider Demographics
NPI:1760006621
Name:SORENSON, BRIGHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIGHAM
Middle Name:
Last Name:SORENSON
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 1:6223 W CAROL ANN WAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-2915
Mailing Address - Country:US
Mailing Address - Phone:928-853-5003
Mailing Address - Fax:
Practice Address - Street 1:710 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3100
Practice Address - Country:US
Practice Address - Phone:928-774-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010687122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist