Provider Demographics
NPI:1508528761
Name:KDST DENTAL
Entity Type:Organization
Organization Name:KDST DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-756-0933
Mailing Address - Street 1:291 N 300 E STE B
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-1881
Mailing Address - Country:US
Mailing Address - Phone:801-756-0933
Mailing Address - Fax:
Practice Address - Street 1:291 N 300 E STE B
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1881
Practice Address - Country:US
Practice Address - Phone:801-756-0933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KDST DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty