Provider Demographics
NPI:1902285190
Name:NAKKEN, BRANDON (DDS)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NAKKEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N GATEWAY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-6102
Mailing Address - Country:US
Mailing Address - Phone:435-787-2223
Mailing Address - Fax:
Practice Address - Street 1:65 N GATEWAY DR STE 1
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-6102
Practice Address - Country:US
Practice Address - Phone:435-752-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10335222-89031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1902285190Medicaid