Provider Demographics
NPI:1760500110
Name:MANSELL, KEVIN LLOYD (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LLOYD
Last Name:MANSELL
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 1:1030 E 11400 S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-6902
Mailing Address - Country:US
Mailing Address - Phone:801-572-2250
Mailing Address - Fax:801-572-2337
Practice Address - Street 1:1030 E 11400 S
Practice Address - Street 2:SUITE 102
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-6902
Practice Address - Country:US
Practice Address - Phone:801-572-2250
Practice Address - Fax:801-572-2337
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5597760-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist