Provider Demographics
NPI:1568624690
Name:DEVRIES, BRADLEY EDWARD (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:EDWARD
Last Name:DEVRIES
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 1:1291 W 12600 S STE 104
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7130
Mailing Address - Country:US
Mailing Address - Phone:801-254-4161
Mailing Address - Fax:
Practice Address - Street 1:1291 W 12600 S STE 104
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7130
Practice Address - Country:US
Practice Address - Phone:801-254-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6945665-99231223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice