Healthcare Provider Details

I. General information

NPI: 1447549837
Provider Name (Legal Business Name): KDB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3688 CAMPUS DR STE 220
EAGLE MOUNTAIN UT
84005-4669
US

IV. Provider business mailing address

3688 CAMPUS DR STE 220
EAGLE MOUNTAIN UT
84005-4669
US

V. Phone/Fax

Practice location:
  • Phone: 801-341-7999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number49554449923
License Number StateUT

VIII. Authorized Official

Name: ERIC MARTIN
Title or Position: PRESIDENT/PEDIATRIC DENTIST
Credential: DDS
Phone: 801-676-8899