Provider Demographics
NPI:1710450655
Name:KELLY D. CARROLL D.D.S., PC
Entity Type:Organization
Organization Name:KELLY D. CARROLL D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-943-2020
Mailing Address - Street 1:2114 E FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3142
Mailing Address - Country:US
Mailing Address - Phone:801-943-2020
Mailing Address - Fax:801-943-3394
Practice Address - Street 1:2114 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3142
Practice Address - Country:US
Practice Address - Phone:801-943-2020
Practice Address - Fax:801-943-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty