Provider Demographics
NPI:1487546305
Name:WALLACE, BRADLEY (DMD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5327 W CANARY GRASS WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-1399
Mailing Address - Country:US
Mailing Address - Phone:801-662-8371
Mailing Address - Fax:
Practice Address - Street 1:853 E 9400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3655
Practice Address - Country:US
Practice Address - Phone:801-572-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14228509-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice