Provider Demographics
NPI:1154497873
Name:OBRIEN, KELLY E (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:E
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4113
Mailing Address - Country:US
Mailing Address - Phone:801-328-2803
Mailing Address - Fax:801-328-2813
Practice Address - Street 1:107 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4113
Practice Address - Country:US
Practice Address - Phone:801-328-2803
Practice Address - Fax:801-328-2813
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT03755449922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist