Provider Demographics
NPI:1649848904
Name:TINGEY, BRENDON THUESON (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENDON
Middle Name:THUESON
Last Name:TINGEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BRENDON
Other - Middle Name:THUESON
Other - Last Name:TINGEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:14407 MURDOCK PEAK DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1855
Mailing Address - Country:US
Mailing Address - Phone:801-792-2510
Mailing Address - Fax:
Practice Address - Street 1:11501 S 4000 W STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-6028
Practice Address - Country:US
Practice Address - Phone:801-701-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12797324-9923122300000X
IADDS-098931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice