Provider Demographics
NPI:1902556582
Name:BENTLEY, BRADLEY JORDAN (RDN)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JORDAN
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 S 100 W APT 7
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3594
Mailing Address - Country:US
Mailing Address - Phone:801-674-1112
Mailing Address - Fax:
Practice Address - Street 1:652 S MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7049
Practice Address - Country:US
Practice Address - Phone:435-251-3793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8338278-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered