Healthcare Provider Details

I. General information

NPI: 1285959353
Provider Name (Legal Business Name): CHAD T EARDLEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 427 BOX 1120
APO AE
09630
US

IV. Provider business mailing address

645 S KNIGHTS WAY
KAYSVILLE UT
84037-6901
US

V. Phone/Fax

Practice location:
  • Phone: 123-456-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6743853-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: