Provider Demographics
NPI:1750574810
Name:PERIODONTAL SPECIALISTS
Entity type:Organization
Organization Name:PERIODONTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-652-1605
Mailing Address - Street 1:754 S MAIN ST STE 7
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5517
Mailing Address - Country:US
Mailing Address - Phone:435-652-1605
Mailing Address - Fax:435-652-2046
Practice Address - Street 1:754 S MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5517
Practice Address - Country:US
Practice Address - Phone:435-652-1605
Practice Address - Fax:435-652-2046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2752191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty