Provider Demographics
NPI:1760748826
Name:CARTER, BRADLEY TYSEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:TYSEN
Last Name:CARTER
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 1:2120 S 700 E
Mailing Address - Street 2:STE I
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1894
Mailing Address - Country:US
Mailing Address - Phone:801-487-0760
Mailing Address - Fax:
Practice Address - Street 1:2120 S 700 E
Practice Address - Street 2:STE I
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1894
Practice Address - Country:US
Practice Address - Phone:801-487-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8586670-9922122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program