Healthcare Provider Details

I. General information

NPI: 1093750101
Provider Name (Legal Business Name): KENT KINGDON ARBUCKLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 S MAIN ST
CENTERVILLE UT
84014-2292
US

IV. Provider business mailing address

281 S MAIN ST
CENTERVILLE UT
84014-2292
US

V. Phone/Fax

Practice location:
  • Phone: 801-292-0733
  • Fax: 801-298-5336
Mailing address:
  • Phone: 801-292-0733
  • Fax: 801-298-5336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number131153-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: