Provider Demographics
NPI:1174741227
Name:BRIDGE, ROD J (DDSPERIODONTIST)
Entity type:Individual
Prefix:DR
First Name:ROD
Middle Name:J
Last Name:BRIDGE
Suffix:
Gender:M
Credentials:DDSPERIODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 N 500 W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1472
Mailing Address - Country:US
Mailing Address - Phone:801-374-8002
Mailing Address - Fax:801-371-0393
Practice Address - Street 1:745 N 500 W
Practice Address - Street 2:SUITE 102
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1472
Practice Address - Country:US
Practice Address - Phone:801-374-8002
Practice Address - Fax:801-371-0393
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT221501223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics