Provider Demographics
NPI:1871862664
Name:PATCH, BRADLEY GEORGE (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GEORGE
Last Name:PATCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 E 200 N
Mailing Address - Street 2:# 4
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4049
Mailing Address - Country:US
Mailing Address - Phone:435-512-6566
Mailing Address - Fax:
Practice Address - Street 1:167 E 200 N
Practice Address - Street 2:# 4
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4049
Practice Address - Country:US
Practice Address - Phone:435-512-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14415599221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0405787210Medicaid