Provider Demographics
NPI:1336880913
Name:BULLOCH, BRANDON SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:BULLOCH
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 1:754 S MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5519
Mailing Address - Country:US
Mailing Address - Phone:435-635-1491
Mailing Address - Fax:
Practice Address - Street 1:754 S MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5519
Practice Address - Country:US
Practice Address - Phone:435-635-1491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12751596-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice