Provider Demographics
NPI:1770842593
Name:EDDIE FADDIS, DDS, PC
Entity Type:Organization
Organization Name:EDDIE FADDIS, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-785-8835
Mailing Address - Street 1:533 W STATE RD
Mailing Address - Street 2:STE 202
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2114
Mailing Address - Country:US
Mailing Address - Phone:801-785-8835
Mailing Address - Fax:801-785-9629
Practice Address - Street 1:533 W STATE RD
Practice Address - Street 2:STE 202
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2114
Practice Address - Country:US
Practice Address - Phone:801-785-8835
Practice Address - Fax:801-785-9629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1456251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty