Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 9021109-9921 | UT |
NPI | 1083973002 |
---|---|
Provider Name | Bryan Glen Trump |
First Address | Salt Lake City, UT 84108-1213 |
Second Address | Salt Lake City, UT 84108-1213 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2012 |
Last Update Date | 20/12/2021 |