Provider Demographics
NPI:1326201765
Name:WILKINS, KELLY C JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:C
Last Name:WILKINS
Suffix:JR
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 1:2274 NORTH 400 EAST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-7241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2274 NORTH 400 EAST
Practice Address - Street 2:SUITE 204
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7241
Practice Address - Country:US
Practice Address - Phone:801-399-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7190754-9921122300000X
AZD75831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice