Provider Demographics
NPI:1851478572
Name:GRANTSVILLE DENTAL CLINIC PC
Entity Type:Organization
Organization Name:GRANTSVILLE DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-884-3476
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:14 N. HALE STREET
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-0706
Mailing Address - Country:US
Mailing Address - Phone:435-884-3478
Mailing Address - Fax:435-884-6790
Practice Address - Street 1:14 N HALE ST
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-9315
Practice Address - Country:US
Practice Address - Phone:435-884-3476
Practice Address - Fax:435-884-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1350971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty