Provider Demographics
NPI:1407949175
Name:MAUGHAN, KENNETH CRAIG JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CRAIG
Last Name:MAUGHAN
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 1:167 N 400 W
Mailing Address - Street 2:SUITE A4
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1909
Mailing Address - Country:US
Mailing Address - Phone:801-226-3302
Mailing Address - Fax:801-226-3535
Practice Address - Street 1:167 N 400 W
Practice Address - Street 2:SUITE A4
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1909
Practice Address - Country:US
Practice Address - Phone:801-226-3302
Practice Address - Fax:801-226-3535
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53282151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT42-158147OtherTIN NUMBER