Provider Demographics
NPI:1760059737
Name:GUNNELL, CHAD ALDEN
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:ALDEN
Last Name:GUNNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 W 5700 S
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84339-9767
Mailing Address - Country:US
Mailing Address - Phone:143-599-4464
Mailing Address - Fax:
Practice Address - Street 1:1320 N 600 E STE 2
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2474
Practice Address - Country:US
Practice Address - Phone:435-752-1747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1232636999221223G0001X
UT1232636099221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty