Provider Demographics
NPI:1740678044
Name:BROTHERS GARDINER LLC
Entity type:Organization
Organization Name:BROTHERS GARDINER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRYTNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-789-4414
Mailing Address - Street 1:3700 CAMPUS DR
Mailing Address - Street 2:STE 200A
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4505
Mailing Address - Country:US
Mailing Address - Phone:801-789-4414
Mailing Address - Fax:801-789-4415
Practice Address - Street 1:3700 CAMPUS DR
Practice Address - Street 2:STE 200A
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-4505
Practice Address - Country:US
Practice Address - Phone:801-789-4414
Practice Address - Fax:801-789-4415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty