Provider Demographics
NPI:1528551603
Name:CHITTENDEN, KEVIN (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CHITTENDEN
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 1:504 W FOX CHASE DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-4713
Mailing Address - Country:US
Mailing Address - Phone:425-870-3325
Mailing Address - Fax:
Practice Address - Street 1:2010 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1621
Practice Address - Country:US
Practice Address - Phone:425-870-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1084664899221223G0001X
AZD0106291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice