Provider Demographics
NPI:1003858432
Name:FADDIS, KELLY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:FADDIS
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 1:11760 S 700 E
Mailing Address - Street 2:#110
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6604
Mailing Address - Country:US
Mailing Address - Phone:801-571-6688
Mailing Address - Fax:801-571-7787
Practice Address - Street 1:11760 S 700 E
Practice Address - Street 2:#110
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6604
Practice Address - Country:US
Practice Address - Phone:801-571-6688
Practice Address - Fax:801-571-7787
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144920-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87-0581297OtherFEDERAL ID #