Provider Demographics
NPI:1629178728
Name:MCKELL, MARK D (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MCKELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N 500 W
Mailing Address - Street 2:# 204
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1541
Mailing Address - Country:US
Mailing Address - Phone:801-374-2182
Mailing Address - Fax:801-374-0130
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:# 204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1541
Practice Address - Country:US
Practice Address - Phone:801-374-2182
Practice Address - Fax:801-374-0130
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144960-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice