Provider Demographics
NPI:1831405513
Name:BRAD A. WAHLSTROM, D.D.S., P.C.
Entity type:Organization
Organization Name:BRAD A. WAHLSTROM, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-566-3003
Mailing Address - Street 1:7089 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3420
Mailing Address - Country:US
Mailing Address - Phone:801-566-3003
Mailing Address - Fax:801-568-1710
Practice Address - Street 1:7089 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3420
Practice Address - Country:US
Practice Address - Phone:801-566-3003
Practice Address - Fax:801-568-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4791609-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty