Provider Demographics
NPI:1003962960
Name:CARROLL, KELLY D (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:CARROLL
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 1:4023 E PROSPECTOR DR
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-733-5858
Mailing Address - Fax:
Practice Address - Street 1:2114 FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-943-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT32519999221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice