Healthcare Provider Details

I. General information

NPI: 1053471896
Provider Name (Legal Business Name): JOSEPH FELLER DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E 500 S SUITE 201
BOUNTIFUL UT
84010-3882
US

IV. Provider business mailing address

625 E 500 S SUITE 201
BOUNTIFUL UT
84010-3882
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-3467
  • Fax: 801-295-5786
Mailing address:
  • Phone: 801-295-3467
  • Fax: 801-295-5786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8972
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5852983
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: