Provider Demographics
NPI:1275097859
Name:CARLISLE, KELLY ROSS (DMD, BS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ROSS
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:DMD, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 W 3200 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:408-621-7744
Mailing Address - Fax:
Practice Address - Street 1:535 E 500 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-3873
Practice Address - Country:US
Practice Address - Phone:801-292-7807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11287528-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist